Access Health at Northwest Hospital

Access Health at Northwest Hospital Program is an outreach and short-term care coordination program designed to provide care coordination and support to patients who have been identified as a vulnerable high cost admission, as a result of chronic illness and high utilization of the Northwest Hospital Emergency Department (ED). The HCAM Care Coordination Team (CCT) consists of a Clinical Team Lead Care Manager (LCSW-C), who work directly and in coordination with the Northwest Hospital ED Nurse Navigator during day, evening, and weekend hours. The CCT provides services on-site at the Northwest Hospital ED which facilitates ongoing interaction with the Northwest Hospital admitting providers and care management staff on a daily basis. Additional services will be provided in the community and in the patients’ homes as necessary based on each patient’s individual health needs. The patients who could benefit from this program most are those that have the following needs:

• Uninsured
• No primary care provider
• Pregnant without prenatal care
• Unmanaged chronic conditions (not terminal)
• Medication non-adherence
• Pain management support
• Substance abuse issues
• Diagnosed mental health condition
• Homeless/housing barrier
• Transportation barrier

This interdisciplinary approach to care coordination assures that the holistic needs of the client are met at the time of the ED hospital encounter.