Care Coordination

Evergreen Health’s care coordinators are here to help patients who are enrolled in Medicaid and living with one or more qualifying chronic health condition meet their health goals. We understand how overwhelming the healthcare system can be, and we’re here to help you access the care and supportive services you need to live your healthiest life while making sure all of your providers are communicating about your care.

Care coordination is available at Evergreen Health in Buffalo and Jamestown.

What do care coordinators do?

Care coordinators help you create a care plan by reviewing your needs and health goals. They make sure that your doctors, specialists and providers are communicating with each other about your unique needs. Care coordinators also help you navigate the healthcare system — from finding providers and scheduling appointments to arranging for additional supportive services — to ensure you have what you need to follow your care plan.

Care coordinators can help you:

• find a doctor or specialist
• make sure doctors are talking to each other about your care
• advocate for your care
• help you understand and remember confusing information
• schedule appointments, tests and more
• get transitional care after discharge from the hospital
• get into mental health or substance user health programs
• link with transportation resources
• apply for financial services and entitlements through DSS, SSA, HEAP and more
• find education or job training programs
• get nutrition counseling and food pantry items
• link with housing assistance programs
• access community and social support
• prepare for life changes

Who is eligible for care coordination services?

Care coordination services are available for patients of Evergreen Health in Buffalo or Jamestown who are enrolled in Medicaid and are living with one or more qualifying chronic conditions. Ask your provider if care coordination is available for you.