At Gillette Children’s Specialty Healthcare, coordinating our patients’ care is a top priority. One way we do this is by using a care coordination team.
Your Gillette care coordination team includes:
- Appointment coordinator
- Nurse coordinator
- Social work coordinator
- You (parent/legal guardian coordinator)
Support for You
The team recognizes that you are your child’s primary care coordinator and a vital member of the team. To help and support you, the Gillette team members work with you to:
- Understand your goals and priorities regarding your child’s care.
- Identify everyone involved in your child’s care. This includes your child’s primary health care provider or pediatrician, Gillette specialists, other specialists, home care nurses, pharmacies, equipment providers, personal care attendants, school staff, and others.
- Encourage communication and sharing of information among the people involved in your child’s care.
- Develop a shared plan of care for your child that includes goals and addresses your child’s health needs.
- Provide you with a single contact person within Gillette, who helps with questions or concerns and celebrates successes. This team member will meet you and your child at St. Paul clinic appointments and call you monthly to check in.
Care Coordination Team Member Responsibilities
Each care coordination team member has different responsibilities.
- Schedule appointments that best fit you and your child’s schedule
- Know your preferred clinic locations for appointments
- Coordinate visits with non-Gillette facilities, for families traveling long distances
- Inform you of any changes in your child’s appointment schedule
- Address your health-related questions or concerns and keep you updated on how previous questions and concerns are being addressed
- Keep your child’s plan of care up to date by working with Gillette health care providers and nurses before and after appointments, tests and procedures
- Work with your child’s Gillette health care providers to obtain orders for equipment, procedures or lab work
- Communicate with your child’s primary health care provider or pediatrician after Gillette clinic visits and hospitalizations
- Communicate changes in your child’s plan of care to school nurses, teachers and home care nurses
- Help you find a pediatrician or primary health care provider for your child
- Collaborate with the social work coordinator to address your child and family’s questions about services
Social Work Coordinator
- Understand your child and family’s service needs, including:
- County services (waivers, mental health, economic assistance, housing)
- Financial assistance (insurance, supplemental security income, individual health care grants, programs to fund equipment/medical needs)
- Lodging, meals and/or transportation for Gillette clinic visits and hospitalizations
- Housing or home accessibility needs
- Legal needs (guardianship, health care directives)
- Address your service-related questions or concerns, and keeping you updated on how previous questions and concerns are being addressed
- Identify service resources in your community that can help meet the care plan goals
- Collaborate with the nurse coordinator to address questions or concerns about your child’s health
- Help you understand how to navigate “‘the system” and advocate for your child
- Coordinate and attend care conferences at your child’s school, your child’s primary health care provider’s office, or Gillette
- Ensure home care services and equipment are in place before your child returns home from the hospital
- Help family members understand or adjust to your child’s diagnosis or changes in your child’s condition
You (Parent/Legal Guardian Coordinator)
- Contact care coordination team members with any questions or concerns you have about your child’s care
- Explain you and your child’s preferences for scheduling appointments
- Help the team understand your child’s health priorities, your child and family’s service priorities, and your child’s goals
- Work with team members to develop a plan of care that focuses on your child and family’s priorities and goals
- When you need assistance, delegate scheduling, communication or other tasks to members of your Gillette care coordination team
This information is for educational purposes only. It is not intended to replace the advice of your health care providers. If you have any questions, talk with your doctor or others on your health care team. If you are a Gillette patient with urgent questions or concerns, please contact Telehealth Nursing at 651-229-3890.