Integrated Care Coordination

PCCN offers a comprehensive Integrated Care Coordination (ICC) program to patients aligned with its partnered health plans and its participating provider membership. Care coordination reaches across medical and nonmedical domains to address interrelated medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes.

Care coordination is the set of activities in the space between visits, care, and hospital stays. Care coordination activities serve the delivery of integrated health care for patients most vulnerable to care fragmentation.

Effective Care Coordination can result in patient/family’s: 

• Partnerships with professionals/PCP’s
• Satisfaction with services
• Fewer hours per week spent coordinating care
• Less impact on parental employment
• Fewer school absences
• Fewer Emergency Department visits

What does PCCN’s ICC program offer?

Through a team of Navigators, Social Workers, and RN’s, some of what PCCN can provide is the following: 

1. Outreach (Including hard to reach patients)  
2. Transportation coordination
3. Provide diagnosis specific education 
4. Assist in meeting quality measures (Gaps in Care, Immunizations, etc.)
5. Facilitate interdisciplinary conferences     
6. Assist in obtaining mental health services and resources
7. Transition in Care-post hospitalization follow-up (TIC) back into the community with medications, DME, home health, and follow up appointments. 
8. Provide community resources and assistance, some examples include: 
   Schooling, Financial, Food, Housing/Shelter, Support, Parenting, and applying for programs. 

Referring into our Program

If your patient could benefit from Care Coordination services, please tell us how! If you are a PCCN provider and would like to enroll one of your patients into our program, please complete the Provider Referral Form. If you are a patient looking for care coordination assistance, please complete our Patient Self-Referral form. Both of these forms can be found below.

Patients who may benefit from care coordination services may include:

1. Children with Complex Medical Needs: Patients who have multiple chronic conditions, require frequent hospitalizations, or are dependent on medical technology (e.g., ventilators, feeding tubes) often benefit from coordinated care to ensure all their medical and non-medical needs are met.
2. Families Navigating Multiple Systems: Children who are involved with multiple care providers, specialists, and perhaps even social services or educational systems can benefit from a centralized coordination effort to streamline their care and ensure everyone is on the same page.
3. Socioeconomic Challenges: Families facing barriers such as language differences, financial constraints, or lack of access to resources can greatly benefit from care coordination services that help bridge these gaps and ensure the child receives comprehensive care.

Please complete the referral form in its entirety, including what we can assist you with specifically, then send via fax or email.  

Fax: 602-933-4331
Email: PCCNCareManagement [at] phoenixchildrens.com (PCCNCareManagement[at]phoenixchildrens[dot]com)
 

Forms

• Provider Referral Form (Online)
• Provider Referral Form (PDF)
• Patient Self-Referral (PDF)

Our telephonic Care Coordinators are available Monday through Friday from 8am – 5pm. 
Questions about Care Coordination or the referral process, please contact 602-933-7226.