The Baxley HCC will focus on servicing patients, families, community partners and educational sites in Appling, Bacon, Jeff Davis and Wayne Counties. Serving as a Medical Home and COINS service provider, this project will focus truly on needs assessments of each community. Ultimately, building networks of service delivery for “At-risk” patients in these communities to meet their individual needs and promote successful healthy living.
Due to distance of travel, lack of knowledge and inability to miss school or work many times children and young adults with disabilities do not get the outreach coordination that they need to truly be as successful at home, in the community and in the educational setting.
COINS will utilize Care Managers to ensure that Primary Care and Wrap Around Services that are needed are secured for all individuals who participate. This coordination of care will serve as an advocation for the patient, their family and the communities to be able to ensure that the patients get the best opportunities for care available. A major focus of COINS Care Managers will be to ensure patient regression or delay in services are prevented by eliminating gaps of care in transportation, communication with schools, employers and providers.
Basic needs of at-risk populations are met at minimal levels in many rural areas of Georgia and the United States. Lack of access to these services is the number one factor affecting the ability for the appropriate intervention(s) to be implemented to this population. Partnerships with local providers, telemedicine consultations and higher education institutions will bridge gaps of intervention needs and build a service delivery option that meet the needs of the patient, their family and the community. Education and training will be supported for areas of intervention where resources are limited or not available or limited, but, needed in the service areas (AB Therapist, RBT’s, Psych-Mental Health Providers). Preceptorships will be coordinated in rural areas where intervention needs are the highest to support growth of long-term service providers for the areas.
Referral for COINS services will be coordinated through a network model. Education of parents, care givers, family members, educators and community members will be a focal point of all COINS service team members. The Project Director will develop screening and referral tools for care and then educate all partners on the service lines, delivery methods and access outcomes quarterly. Bi-annually, the network partners will come together for information dissemination, resource evaluations and recommendations for new service line implementation that may be needed for the COINS service areas.
Specialty services will be brought to the home, school and/or communities through direct care delivery or telemedicine as applicable and needed for each patient. ABA Therapists, Registered Behavior Technicians, Speech Language Pathologists, Occupational Therapists, Physical Therapists, Licensed Clinical Social Workers, Psychologists, Primary Care Providers, Psychiatrists and other Licensed Mental Health Service Providers will build interdisciplinary plans to promote improved outcomes in the home, school and community for the clients and their families served through this project.
Community, Outreach, Intervention, Network, Services