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Integrated Care Coordination

Phoenix Children's Care Network (PCCN)

What is Integrated Care Coordination (ICC)?

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
  • Ease of getting referrals
  • Lower out of pocket expenses and family financial burden
  • Fewer hours per week spent coordinating care
  • Less impact on parental employment
  • Fewer school absences
  • Fewer ED 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. Scheduling appointments    
  4. Assist with and facilitate referrals
  5. Provide education 
  6. Assist in meeting quality measures (Gaps in Care, Immunizations, etc.)
  7. Facilitate interdisciplinary conferences     
  8. Assist in obtaining mental health services and resources
  9. Transition in Care-post hospitalization follow-up (TIC) back into the community with medications, DME, home health, and follow up appointments. 
  10. 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 providers 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.

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
We are happy to assist however we can.


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

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