Care coordination

We support clinical integration through standardized approaches to care coordination and population health strategies. Patients and families often struggle with chronic or complex health conditions, developmental issues or social service needs.

Our care coordinators are registered nurses and social workers who identify community resources for patients and help them navigate medical, psycho-social, financial, legal, mental health and transportation issues.

We promote coordinated transition of care for patients of all ages across multiple care settings to keep patients healthy and out of the hospital when appropriate.

Care coordination
We provide telephonic nurse and social work case management for UCare Medicare Advantage™ and UCare Medicare Plans™ members to support care transitions and long-term care coordination.
Care packages
Improving quality of care and experience, reduce cost
Care packages provide consistent, evidenced-based tools to support consistent care across our clinics.

Care packages support processes that help patients receive appropriate screening and diagnostic procedures. We work to reduce inappropriate use of services, such as unnecessary hospital readmissions and emergency visits.

Through care packages, we work to support patients so they feel heard and motivated to participate actively in their care. We offer the following care packages:
• Asthma
• Chronic Kidney Disease
• Depression
• Diabetes and cardiovascular disease
• Heart failure
• Low back pain
• Migraine
• Pediatric ADHD
• Adult preventative care
• Pediatric preventive care

Medication therapy management
Our specially trained medication therapy management (MTM) pharmacists work closely with patients and doctors to identify, resolve and prevent medication-related problems. Network providers and care coordinators can refer patients of independent Fairview Health Network primary care clinics for medication therapy management at no cost to the patient or the independent practice.

Discrimination is Against the Law. We comply with applicable Federal civil rights laws. We do not discriminate against, exclude or treat people differently because of race, color, national origin, age, disability or sex.
© 2018 Fairview Physician Associates Network. All rights reserved.