Program Highlight: Care Coordination

When Jenna*, a young mom with two kids, came to the ROC, she was struggling to make ends meet. She had just left an abusive relationship and needed help finding new housing. Her children needed school supplies and clothing. She felt frustrated, stuck, and hopeless. 

Jenna is one of the many people who come to the ROC with a variety of challenges that need to be addressed.  In rural areas like the ROC’s service area, resources are often spread out across multiple agencies.  Solving these challenges can be hard, especially for someone who may not even know that there are resources available.   

That is where care coordination comes in. When people come to the ROC with a variety of needs, they meet with our care coordinator Kelly.  Her job is to connect people with the resources that will help them meet their needs.   

For Jenna, this meant connecting her with her local food pantry and signing her up for SNAP and HEAP. With Kelly’s help, Jenna was linked with Section Eight vouchers for housing.  All of this means there’s a little more breathing room in the family’s budget and Jenna can make sure her kids have what they need. Jenna was also able to get counseling through the ROC. Now that her basic needs are met, Jenna is excited to start receiving employment assistance through the ROC as well. 

Jenna’s situation was a case where care coordination was a perfect fit – she needed help connecting to resources, but now that she has those connections, she’s confident in her ability to use them to help her family.  We’re happy to share that Jenna and her family are doing well.   

So, what is care coordination? 

The Agency for Healthcare Research and Quality offers this definition: “Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.” 

Navigating systems and accessing resources can be difficult tasks for anyone, let alone someone who is feeling overwhelmed by the situation they find themselves in. Care coordination services centralize initial access to resources and make sure that everyone can access the resources they need to succeed. 

“Care coordination is about meeting people where they’re at and ascertaining what basic human needs they may have – food, housing, medical, etc. – and working with them and linking them to community resources,” Kelly says.  

At the ROC, Kelly works to form connections with other agencies in the community. “It’s extremely difficult in rural areas to access medical attention, mental health services, and transportation. Even food pantries aren’t close. Low-income housing is almost impossible to find,” Kelly says. The connections Kelly makes with other agencies serve to improve the resources the ROC can offer our Participants. 

Care coordination makes a difference by offering solutions to a variety of challenges. The ROC proudly offers care coordination to empower Participants. Every week, we see Participants making exciting progress thanks to the resources and support our care coordination department connected them with

*The ROC changes names and certain details to protect the privacy of those we serve