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17.3. Definition of the Care Coordinator

The Care Coordinator is a professional at the facility-level who coordinates care for a panel of patients throughout the continuum of care to ensure that care is timely, appropriate, of high quality and cost effective. The Care Coordinator works closely with primary care providers, other health care professionals and team members, clinics, internal or external services, and community agencies. The Care Coordinator provides professional assessment, coordination and planning of multiple health care services; acts on behalf of the veteran to ensure that necessary clinical services are provided and that progress is being made. In addition, the Care Coordinator provides ongoing evaluation of care management services. NOTE: Collaboration between PSAS and OCCS programs is essential for effective and efficient management of home telehealth equipment. The PSAS staff works in conjunction with the Care Coordinators to ensure proper procurement and inventory management of the home telehealth equipment.