Care Coordination Services

We are committed to offering our patients and families comprehensive care to address all areas of need impacting health development and wellbeing through our Peak Cares Team.

We understand the holistic and multi-faceted nature of health, which is why we have a collaborative team that serves to assist patients in navigating and accessing community resources and services for medical, developmental, behavioral, neurological, socioeconomic, and family needs.

Our Care Team consists of the following:

  • Health Navigators: If you have a visit to urgent care or the emergency department, our health care navigators follow up on how your child is doing and ensure any follow-up care is established. They are also available to help coordinate transportation to medical appointments and connect families to food banks, housing resources, benefit assistance programs, adult medical providers for parents, and more.

 

  • Referral Coordinator: Our referral coordinator processes and manages all referrals for outside community specialist services and ensures information, evaluations, and test results are shared with our Providers for continuity of care and any needed follow-up. This includes services such as authorized durable medical equipment, speech therapy, occupation therapy, physical therapy, ABA or early intervention for children with neurodevelopmental or other medical conditions that benefit from specialist services.

 

  • RN Nurse Care Coordinators: Our RN Nurse Care Coordinators are available to address any immediate health questions and assess for the appropriate plan of care. For families who have a chronically ill child, they assist with navigating multiple appointments and services and can help follow up with prior authorizations for medications, medical equipment, asthma care plans, and other specialist services.

 

  • Family Support Advocate: Our Family Support Advocate helps families address life circumstances such as parent and family challenges, housing instability, substance use, trauma, abuse, and involvement with outside systems and agencies.Our practice also partners with the Colorado Community Health Alliance (CCHA) of Medicaid to provide extensive care coordination services for designated patients with dynamic medical, developmental, and psychiatric needs. We work collaboratively with families to establish Care Plans to ensure all services, coordination, and access to support occur by all treatment team members.

 

  • Behavioral Health Specialists: Our Behavioral Health Specialists are available during clinic hours to meet with established patients and caregivers to discuss any emotional or behavioral needs. They provide services including consultation, parent and child psychoeducation, case management, referrals to outside mental health therapy providers, and advocacy in navigating community mental health systems and services. They do not provide ongoing counseling services.