Care Coordination > Beacon Health System

Care Coordination > Beacon Health System
Southwest Michigan Borgess patients—Welcome to Beacon
Three Rivers Health Outpatient Clinic Patients: Click here for important information
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https://www.beaconhealthsystem.org/care-coordination/
https://www.beaconhealthsystem.org/care-coordination/
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Care Coordination
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Care Coordination
Coordination of care involves a team effort to provide the highest quality of well-being services. The Beacon Care Coordination Team will collaborate between healthcare teams, providers, families and patients to reach optimal health and wellness.
Our Care Coordination Team:
Provides safe, quality care.
Provides support for chronic healthcare needs.
Assists with medication management.
Helps achieve goals to improve outcomes and quality of life.
Assists in helping to attend appointments with primary care provider and/or specialist.
Assistance with overcoming barriers to obtaining care such as:
Insurance coverage
Medication affordability
Financial concerns
Transportation issues
Information and referrals to community resources
Coordination of programs to achieve the best possible outcomes
Registered Nurses
We realize that you may have questions and concerns. Our nurses will visit with you when you are in the hospital, assure you are ready to leave the hospital, and work with your primary care provider or specialist to develop a plan of care specific to your health needs.
Our goal is to:
Provide education on signs and symptoms to be monitored.
Prepare you with coping skills to better live with your chronic illness.
Follow up with you after a hospital stay.
Establish resources to help you with lifestyle changes.
Promote optimal health and independence.
Home Visits
A registered nurse is available to meet with you in your home or wherever you are most comfortable to discuss your health conditions and concerns, provide education and answer any questions you may have.
A home visit may include support for preventative screenings, help with monitoring appointments and assist you with all stages of your chronic condition. A home visit can help provide education, assistance, goal setting and goal achievement.
Telephone and skype options are also available.
Social Services
We realize it’s necessary to help address social needs that may affect your health care. Our goal is to help you eliminate any barriers to care, and address basic living needs so you can focus on management of your condition.
Our social worker is able to refer you to many options for community and social resources including:
Affordable Housing Programs
Support Groups
Crisis Management
Food Banks
Spiritual Needs
Who could benefit most from this program?
If you have one or more of the following chronic conditions:
Diabetes
Pulmonary issues – Chronic Obstructive Pulmonary Disorder (COPD), Pneumonia
Recent or previous Stroke
Cardiac Issues – Congestive Heart Failure (CHF), Hypertension
Additionally:
Multiple uncontrolled chronic conditions.
Social or economic conditions/disparities that impact the effectiveness of managing care.
Multiple hospital stays due to worsening or uncontrolled chronic condition.
For additional information about Care Coordination or to request a referral, please speak with your physician.
Services
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