Coordinated Care is described as an "ambulatory intensive care unit." This innovative primary care clinic is designed for patients with complex health problems that result in frequent hospitalization. The clinic provides patient-centered, multidisciplinary, team-based care in an effort to reduce the impact of chronic illness on the lives of its clients.
Clinic services include walk-in access for new issues, close medical follow-up after hospitalization, regular oversight by clinic pharmacists through medication therapy management, and intensive attention to behavioral and social determinants of health. Clinic-based nurse coordinators and social workers team to organize and facilitate care within the health system as well as the community.
This clinic is available to patients by professional referral only. New patients to the clinic typically have three or more hospitalizations in the year preceding clinic enrollment.