Clinical Care Coordinators and Care Collaboration Case Managers provide a unique blend of assistance to help patients identify ways to function in their environment after diagnosis or discharge, while managing the multiple pieces of information obtained from other health care professionals that will assist them to make the best decisions possible in planning for their long-term wellness. Their role is to work with the patient and the family on a short-term basis to teach and empower the patient and their family to take the lead to manage their health care.

Case management services include

• providing advocacy and assisting patients to identify then meet unmet health care needs

• assisting in planning and coordinating health services appropriate to achieve the goal of medical rehabilitation

• implementing the medical treatment plan initiated by the Clinical Care Coordinator

• monitoring and working closely with the patient, their family, and health care providers to assist the patient to fulfill their health care needs.

Clinical care coordination services

• providing psycho-social support and education to assist in coping with chronic, acute, or terminal illness and disability

• assisting patients and families receive follow-up care by providing information, referral and linkages to health care resources

• explaining health care resources and policies to patients, their families and professional staff

• collaborating with Discharge Planners for post-discharge medical needs and services

• coordinating with Seneca Nation departments and ancillary agencies to meet patient’s health care needs

• providing medical advocacy for the patient to appropriate organizations and medical personnel