Community Health

Coordinated Care and Community Health is a growing program that seeks to meet the complex healthcare needs of our patient population. Case Managers and Community Health Workers are part of an integrated team that assist patients with addressing social health needs such as housing, transportation, food and access to medical care. We strive to meet patients where they are and help create a plan to achieve your goals. We also conduct community outreach and education with the goal of improving the overall health and well-being of our community.

Case management is a long-term service for people who need help creating and maintaining health goals for their chronic conditions or mental illness. Our case managers help collaborate care between appointments and keep patients on track for their multiple whole person health needs.

Enhanced Care Management is a whole-person, interdisciplinary approach to care that addresses the clinical and non-clinical needs of our patients who are experiencing homelessness or are utilizing the emergency room as their primary source of care. Learn more about Enhanced Care Management.

Blood Pressure Monitoring Program is available to our patients who have been diagnosed with hypertension. The patient is provided a blood pressure cuff to utilize at home that sends their daily blood pressure reading to our clinic staff who will monitor daily and work with the patient to address their health condition needs.