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Care Management and Specialty Referrals

Care Management is a team-based, patient-centered approach, which is designed to assist our patients and their support systems in managing medical conditions more effectively. Here at Florida Community Health Center we take pride in offering an effective program to help improve disease control and self-management, reduce distress, prevent admissions or readmissions, and improve the coordination of care for all of our patients’ regardless of the complexity of health.

Care management means a set of patient-centered, goal-oriented, culturally relevant and logical steps to assure that the patient receives needed services in a supportive, effective, efficient, timely and cost-effective manner.

At a minimum, care management functions must include, but are not limited to:

  1. Early identification of patients who have or may have special needs;
  2. Assessment of an patient’s risk factors;
  3. Development of a plan of care;
  4. Referrals and assistance to ensure timely access to providers/clinicians;
  5. Coordination of care actively linking the patient to providers/clinicians, medical services,
    residential, social, behavioral, and other support services where needed;
  6. Monitoring;
  7. Continuity of care; and
  8. Follow-up and documentation.

Care management is driven by quality-based outcomes such as: improved/maintained functional status, improved/maintained clinical status, enhanced quality of life, patient satisfaction, adherence to the care plan, improved patient safety, cost savings, and patient autonomy.

The FCHC Referral Department is a Centralized team that focuses on bridging the gap between the Primary and the Specialist Care that our patients need. The team focuses on getting the Referrals, authorizations processed and approved and appointments scheduled for patients to get the care needed outside of FCHC Primary and Specialty scope. The Referral Department also focuses on closing the Referral gap by tracking referrals and getting the Primary Clinician notes back from the Specialist and Radiology facilities to close the loop for PCMH.

The Referral Specialists are responsible for referral operations for assigned centers, establishing and standardizing systems for the distribution and use of health information, coordinating and referral functions with other outside specialty offices for patients’ continuation of care. The Referral Staff act as the system navigator and point of contact between the Primary, Specialist, and Insurance for the patient to get the service of specialty care needed.