Care Coordination

What is Care Coordination?

The Care Coordination Programs at Knox Community Hospital aim to ensure that patient concerns, needs and preferences for health services are met.

These teams also ensure that information which is shared across various channels, functions or sites of care. Care Coordination works with families and caregivers to track, aid and assess the best possible plan of care for those in transitional or chronic care conditions.

What is Chronic Care Management?

Chronic Care Management is a service provided to you by your provider, a nurse care coordinator, and other healthcare team members on a monthly basis. Under this program, you will work with this team to create the most complete Care Plan to best manage your long term health needs.

How do I qualify?

Chronic Care Management is available to any consenting person with two or more chronic conditions expected to persist at least 12 months that place you at risk of becoming worse.


  • A personalized Care Plan developed by you and your healthcare team
  • A minimum of 20 minutes of non-face-toface care from your care coordinator
  • Medication reconciliation and monitoring
  • Referrals to appropriate services and healthcare
  • Management of care transitions from one level of care to another
  • 24/7 access to your care team and regular communication through your choice of method – telephone, e-mail, or your patient portal
  • Assistance in managing appointments

What is Transitional Care Management?

Transitional Care Management refers to the coordination and continuous delivery of health care services from an inpatient setting to the community.


  • Contact from your Care Coordinator within 48 hours of your inpatient discharge
  • Regular communication by your Coordinator for 30 days to assist in your transition and wellness
  • Assistance with finding transportation to appointments
  • Follow-up with your primary care provider within 7-14 days of discharge from the hospital or skilled nursing facility
  • Communication with home health agencies and other community services used by you
  • Support for treatment and medication reconciliation and monitoring
  • Referrals to appropriate community services as needed
  • Reminders/assistance with scheduling appointments with your primary care provider or assistance with finding a primary care provider