Clinical Services

Whittier Care Coordination Program

Whittier has instituted a care coordination system as part of its Boston Health Equity Project. Care coordination is the deliberate integration of patient care activities between two or more participants involved in a patients care to facilitate the appropriate delivery of health care services. It refers to activities and interventions that attempt to reduce fragmentation and improve the quality of care, support, referral and transition plan for patients. There are three levels of patient support needed:

Highest risk population management

Clinical Care coordination: (LPN) Monitoring hospital and ER utilization and hospital discharge reports, medication management. Case managing high-risk patients post hospital discharge. Checking in with patient’s shortly after discharge from ER or hospitals.

Integrated Clinical Care Management- High-risk.

Clinical Follow-up Care: (Case managers) Chronic disease support and cancer screening and cancer diagnosis support.

Population health management- Low risk.

Care Coordination: (Office Managers, medical assistants) Managing e-referral system, assuring transfer of referral information both ways, helping to make appointments.

Fax Number: (617) 989-3086