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Care Coordination

Lake Okeechobee Rural Health Network (LORHN) has Community Health Workers on staff to deliver direct services to priority residents in the rural communities surrounding Lake Okeechobee. Our Community Health Workers meet the consumers where they are, identify needs and help the consumer set goals to improved health for the long term. Consumers can learn how to communicate effectively and self-advocate across the healthcare system and in the community. LORHN believes that when consumers know how to manage their chronic health conditions, they have better outcomes and improved health.

Our priority populations for the Care Coordination Program include rural residents with any of the following:

  • Two or more emergency room (ER) visits within the last six months
  • Two or more inpatient admissions within the last year
  • Hospital readmission within thirty (30) days of discharge for the related condition
  • No medical home or primary care provider within the last year
  • Complex or chronic medical/behavioral health conditions
  • Other identified needs

If you would like care coordination services for yourself or another consumer please complete our Care Coordination Referral Form (link to: “Referral Form ALL”), and a member of LORHN’s Care Management Team will contact you once the form is received.

The referral is a starting point to assist with identifying needs, recommended services, linkages and potential resources for the consumer. LORHN’s Care Management Team will contact the consumer to:

  • Complete a thorough assessment
  • Develop a customized plan
  • Help the consumer set personalized goals
  • One-on-one assistance is provided to consumers such as:
    • Help to make appointments
    • Location of resources
    • Make linkages
    • Accessing health records
    • Organizing health records

For consumers and providers, the LORHN care management team will ensure:

  • Referring agencies receive status updates
  • Assist with preventing a duplication of services
  • Share information between consumer, provider and referred agencies
  • Consumers receive services for up to sixty (60) days, or longer if needed
  • Utilization data, surveys and other related health data will be analyzed to help measure health impacts