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What We Do

Regional Care Coordination- Regional Care Collaborative Organization (RCCO)

NCCHP’s care coordinators are helping medical and non-medical services work together to improve overall patient health, support improved clinical care and link patients and providers with community resources. Our care coordination program spans all health care and wellness programs.

We have embedded Community Care Coordinators where they are needed most; during transitions in care, frequent emergency room visits and chronic medical problems. By committing to helping our residents overcome obstacles, and navigate the complex health care and community systems we are reaching healthcare goals every day. 

  • Improve transitions of care 
  • Improve treatment speed and quality of care
  • Improve patient satisfaction

Through a strong partnership between Northwest Colorado Community Health Partnership, Rocky Mountain Health Plans, Colorado ACC Medicaid members, Colorado Department of Health Care Policy and Financing, Primary Care Medical Providers, Community resources/groups, Hospitals, Specialists, Single Entry Point (SEP) agencies, we are providing care coordination services to individuals in Routt, Moffat, Rio Blanco, Jackson, and Grand counties.  

NCCHP Care Coordination Region

Care Coordination Process

Step 1.  We require an initial intake assessment on all referrals to the Northwestern Colorado Community Health Partnership. This helps our coordinators prioritize what assistance is needed.  Care coordination cannot happen until an assessment has been completed and the client agrees to care coordination.   

Step 2.  Once the intake assessment has been completed and client agrees to care coordination, our community care coordinators can help by:   

  • Addressing transportation issues to Medical or Mental Health appointments   
  • Providing education and connection to community resources (food banks, housing, senior resources, etc).  
  • Assisting with paperwork regarding resources, medical or mental health services   
  • Coordinating Medicaid providers and services (dental, eye Care, hearing screens, appointments, specialty referrals, etc.)    
  • Facilitating communication across systems such as behavioral health, long term care and specialists   
  • Promoting client self-efficacy   
  • Locating necessities (hearing aids, canes, dentures, etc)    
  • Developing care plans with the patient, family/caregivers, providers, and RCCO organizations 
  • Identifying family and client’s strengths, cultures and values.  

Empowering and creating goals with your client makes them an active participant in their health, leading to a higher success rate.    

Step 3. Once care plan goals are consistently being met and clients are in control in their health, the care coordinator may decrease involvement.