What We Do
RN and Social Worker Care Management
King County Care Partners care management staff (RNs and Social Workers employed by Aging & Disability Services, the Area Agency on Aging) work with high risk clients for up to 12 months. Clients are high-cost Medicaid beneficiaries with behavioral health issues and multiple chronic conditions. Specific objectives include:
- Assess risk factors, health literacy, health status, and self-management skills.
- Screen for alcohol and substance abuse, depression, and other mental health conditions, diabetes, heart disease, and other chronic conditions.
- Assist with education about provider’s treatment plan and prescribed medications.
- Develop a medical treatment plan with the client’s provider, if a plan does not exist.
- Develop a care plan, helping clients set goals for self-management.
- Refer to services that address unmet needs identified in the assessment.
- Help clients address barriers to using the health care system.
- Track measures for evidence-based medicine guidelines for chronic illness.
Clinic Care Coordination
Partnering clinics provide care coordination, monitoring, and oversight for clients who are enrolled in the KCCP program. From initial client engagement until transition to clinic oversight, clinic coordinators play a vital role, advocating for, supporting and assisting clients working on self-care goals.
KCCP Chronic Care Management Handout
- Brochure for Providers
- Brochure for Clients
Policies & Procedures
- Program Manual