Care Coordination

The Care Coordination program of SJBPH is a function that supports information-sharing across providers, patients, types and levels of service, sites and time frames. Care Coordination is most needed by those who have multiple needs that cannot be met by a single clinician or by a single clinical organization, and which are ongoing, with their mix and intensity subject to change over time.

Care Coordination is a benefit of Health First Colorado (Medicaid) designed to provide access, guidance and advocacy to those who face barriers to health care and resources, and to support a community-wide approach to reducing those barriers through systems-level work.

CONTACT

Family Health Coordinator

La Plata County | 970 335 2022

HCP Team

La Plata County | 970 335 2088

Nurse Navigators

Program Manager | 970 335 2002

Regional Oral Health Specialist | 970 335 2034

Archuleta County | 970 264 2409 x203

La Plata County | 970 335 2005

Parents Plus Coordinator

La Plata County | 970 335 2006

CARE COORDINATION SERVICES

Our Family Health Care Coordinator helps Health First Colorado (Medicaid) and CHP+ (Child Health Plan Plus) eligible residents of San Juan, La Plata, Montezuma, Cortez, and Archuleta Counties navigate healthcare systems as well as connect clients to community resources.

Through Health First Colorado’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Outreach, we connect families and pregnant women with resources to obtain treatment for medical, dental, vision, mental health, and developmental problems such as well-child visits, diagnosis and treatment services.

Our Family Health Care Coordinator is available to assist pregnant women and families with applications, access to care, education, referrals, and navigation of services. Do you need help obtaining coverage or accessing your benefits? Visit our Family Health Care Coordinator during offsite help desk hours.

CHP+ offers full health care coverage for uninsured Colorado children and youth (up to 18th birthday) and pregnant women 19 years of age and older. The CHP+ plan includes check-ups and shots, other doctor visits, hospitalization and hospital services, prescribed medications, and mental health services.

The Children and Youth with Special Health Care Needs (HCP) team (HCP Nurse and Family Focus Clinic Coordinator) provides free services for clients and their families who live in Archuleta and La Plata Counties. They may have increased risk for a chronic physical, developmental, behavioral or emotional condition.

Specialty clinics include Pediatric Neurology and Rehabilitation. Our staff can provide referrals, triage, and scheduling for new clinic visits and follow up appointments with visiting doctors from Children’s Medical Center in Denver. They can also assist in coordinating required records from other providers.
There is a sliding fee scale for clinic fees. Health First Colorado (Medicaid) clients have no fee.

  • Intake interview identifies strengths, concerns, culture, and values
  • Assessment considers the special health care needs in more detail
  • Action plan identifies goals, next steps, responsible persons, target dates
  • Review of action plan progress

See below for specialty clinic schedules.

As a community care team, the SJBPH Nurse Navigators serve any Archuleta or La Plata County resident who faces barriers to care or needs assistance navigating the healthcare system. As the area Regional Care Collaborative Organization (RCCO), Nurse Navigators are best equipped to support Health First Colorado (Medicaid) members.

  • Assess for unmet needs (medical, social, financial, behavioral and educational)
  • Identify individual and family strengths
  • Develop a goal oriented plan of care with clients, families and providers
  • Educate towards greater self-management of chronic diseases
  • Help client achieve healthier outcomes

An essential component to community care is oral health. The SJBPH Regional Oral Health Specialist (ROHS) is available in Archuleta and La Plata counties to assist in navigating dental care options for Health First Colorado (Medicaid) community members.

The SJBPH Parents Plus Nurse assists La Plata County residents with parenting, health needs, access to health services, and preventive care. Parents Plus is a nurse case management program which utilizes nursing assessment skills and support in the home or office settings.

Parents Plus Project is part of an inter-disciplinary team led by La Plata County Department of Human Services Temporary Assistance for Needy Families (TANF) Program.

  • To apply for the TANF program, go to the Human Services office at 10 Burnett Ct., Durango, CO or call‎ (970) 382-6150

HCP Specialty Clinic Schedule

Pediatric neurology and orthopedic rehabilitation clinics at SJBPH.

Help Desk Hours

Do you need help obtaining coverage or accessing your benefits? Visit our Family Health Care Coordinator.

OTHER RESOURCES