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Shannon Care Coordination utilizes Registered Nurses and Community Health Workers to help patients reach their healthcare goals by providing support and guidance.

Care Coordination can:

  • Provide chronic disease management.
  • Educate patients on their treatment plans.
  • Provide motivation and accountability support for patients making behavioral and lifestyle changes.
  • Help patients navigate the healthcare system.
  • Facilitate communication with patients and providers.
  • Identify social barriers to care.
  • Offer remote monitoring for certain conditions.
  • Help patients cope with emotional challenges during recovery.

Chronic Care Management Program

Shannon Care Coordination’s Chronic Care Management program is a 6-month program for Medicare patients with a physician referral and two of these conditions:

  • Acute myocardial infarction
  • Alzheimer’s disease
  • Alzheimer’s disease and related disorders/senile dementia
  • Anemia
  • Asthma
  • Atrial fibrillation
  • Benign prostatic hyperplasia
  • Cataracts
  • COPD and bronchiectasis
  • Chronic kidney disease
  • Colorectal cancer
  • Depression
  • Diabetes
  • Endometrial cancer
  • Female or male breast cancer
  • Glaucoma
  • Heart failure
  • Hip/pelvic fracture
  • Hyperlipidemia
  • Hypertension
  • Hypothyroidism
  • Ischemic heart disease
  • Lung cancer
  • Osteoporosis
  • Prostate cancer
  • Rheumatoid arthritis or Osteoarthritis
  • Stroke or Transient ischemic attack

About Chronic Care Management:

During the initial visit (via phone), a Registered Nurse will complete a durable medical equipment (DME) assessment, reconcile all medications, and offer a home visit.

Within 24-72 hours of the initial visit, a Community Health Worker will complete a comprehensive social needs assessment and establish patient access to MyChart.

Visits continue bi-weekly via phone for up to 6 months to provide disease-specific education, comprehensive care plans and care coordination to help navigate the healthcare system.

Transitional Care Program

Shannon Care Coordination’s Transitional Care program is a 30-day program for patients recently discharged with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) and Pneumonia based on discharge diagnosis criteria.

About Transitional Care:

During the initial phone call, a Registered Nurse will reconcile all medications, complete a brief social screening and durable medical equipment (DME) assessment, provide disease-specific education, and offer a home visit with the set-up of remote monitoring.

Within 24-72 hours of the initial visit, a Community Health Worker will complete a comprehensive social needs screening.

Visits continue weekly via phone for 30 days to provide accountability and support, care

navigation, medication support and remote monitoring.

Please note: in-person initial home visits are available for patients within a 30-40 mile radius. Patients outside this area will receive program services and materials via phone and mail.

For referrals or more information about Care Management, contact Shannon Care Coordination at (325) 747-5124.