Creating Health Equity Through Care Coordination

Care Coordinators are good at cold-calling. Most of their work is done by phone. And often they don’t know much about the person they’re calling.

Coordinators call individuals referred by their health plans. The calls begin with a brief introduction, including an explanation that Care Coordination Services are a free health and wellness promotion tool offered by the individual’s insurance plan.

Then the conversation might sound something like this: “I hear you’ve had some hospitalizations.” From there, Care Coordinators work on relationship-building to understand the person’s health status, needs, and overall goals. Common questions are: “What kinds of things could you use help with?” and “How can we help?”

Care Coordinators see clients once a year to complete a full assessment of their health and needs, but mostly they get to know people by phone. “We act as a centralized telephonic delegate on behalf of the insurance company to answer questions, connect people to resources, remind them of appointments, schedule rides, and assure all of their health providers are on the same page,” explains Mel, one of the Coordinators.

To qualify, individuals must have a physical, mental health, or cognitive disability. Services aim to connect them with preventive services that will help them reach their goals in the most efficient, cost-effective way. Individuals receive assistance to develop and use an integrated plan for care, including their physical, mental, and dental health.

Coordinators work with the individual, the health plan, the primary care physician, and others as needed in support of the individual’s goals. “We don’t push our idea of what our goals are on those we work with,” says Melissa Mikkonen, Program Manager. “We really make sure that it’s tied back to their overall goals.”

This level of coordination assures that people are knowledgeable about their health plan and that they know how to access and utilize their benefits. Another Coordinator on the team, Molli, describes the value of Care Coordination Services this way: “We put a human face on what can be a behemoth of an industry. Insurance in general is often confusing, overwhelming and time consuming. When individuals experience this, they don’t access the full benefits available to them. Meaning only their minimal health needs are met, if that. By helping people connect to services and providers consistently to meet their needs, it allows people to more easily attain optimal physical and behavioral health.”

It’s the personal connection that makes a difference. Recent outcomes from the Healthcare Effectiveness Data and Information Set (HEDIS), used by health plans to measure performance on important dimensions of care and service, reflect excellence. The Care Coordination team’s outcomes are exceedingly higher than the national average. “The reason we’re far exceeding national standards,” comments Melissa, Program Manager, “is because we really take the time to build those relationships.”

“The significance of Care Coordination is really health equity,” she says. “It’s really rewarding to get people connected with health services.”


More About Guild’s Care Coordination Services 

  • Provides: Primarily telephonic services with some face-to-face services, including an annual assessment, to help people develop and utilize an integrated plan for care (physical, mental health, and dental) that includes coordination with the health plan and primary care physician, so individuals can meet their goals.
  • Counties served: 7-county metro area
  • Accepts referrals from:  Individuals must be referred to Guild by a health plan we’re contracted with to provide Care Coordination Services.
  • Payment for services: Medical assistance


January 25, 2019

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