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Care Coordination
Some health situations need more support than a standard primary care schedule provides. Managing several chronic conditions at once. Recovering from a hospitalization. Navigating a new diagnosis that involves multiple providers. Trying to keep track of medications, referrals, and follow-up appointments across a fragmented healthcare system.
For patients in those situations, NWPC's Care Coordination team provides an additional layer of support: a care coordinator who works alongside your primary care provider to make sure the pieces of your care are fully connected.
What a Care Coordinator Does
A care coordinator at NWPC is not a replacement for your provider. They are a resource who works between appointments to keep your care moving in the right direction. Your care coordinator can help with:
- Connecting you with resources to support your health and wellness, such as caregiver resources, transitional housing assistance, senior services, and more
- Supporting care transitions after a hospitalization or procedure
- Communicating between your NWPC care team and outside providers on your behalf
For patients who have felt lost between appointments or unsure what was supposed to happen next, care coordination is the structure that closes those gaps.
Who Benefits From Care Coordination
Patients managing multiple chronic conditions simultaneously
Older adults with complex medication regimens or multiple specialists
Patients recovering from a recent hospitalization or major procedure
Newly diagnosed patients needing help understanding their care plan
Anyone who has struggled to keep up with the administrative complexity of their own health care
Patients seeking coordinated care between providers
Care Coordinators primarily work with patients who have complex medical diagnoses or social situations, but are able to provide information and resources for all patients. Our Care Coordinators are also trained in suicide prevention and can help guide patients in crisis through safety planning.
Each clinic location is assigned a designated Care Coordinator who is available for patients who need assistance. If you are not sure if care coordination is the right fit, talk to your NWPC provider at your next visit. They can assess your situation and connect you with the program if it makes sense.
Care Connect
For patients whose conditions benefit from monitoring between appointments, NWPC offers Care Connect, a program that tracks key health metrics in real time. Rather than relying solely on what happens at scheduled visits, Care Connect gives your provider visibility into how your health is trending day to day.
When a metric shifts in a direction that warrants attention, your care team can respond before a small change becomes a larger problem. For patients managing diabetes, hypertension, heart disease, or other conditions where numbers can move between appointments, that kind of continuous oversight changes the nature of care.
Ask your provider about Care Connect at your next visit to find out if it is appropriate for your situation. You can also learn more with the FAQ section below.
Still have questions? Call our Care Connect Dashboard Manager at (503) 607-2070.
Support When You Leave the Hospital
The transition from hospital care back to outpatient care is one of the highest-risk periods for patients with complex health needs. Medications change during a hospital stay. Discharge instructions can be difficult to follow. Follow-up appointments need to happen quickly, and the handoff between inpatient and outpatient care is often where things go wrong.
NWPC's care coordination team supports patients through that transition. We coordinate with the hospital discharge team, review any medication changes, schedule prompt follow-up with your primary care provider, and make sure nothing important gets missed in the handoff.
If you or a family member has been recently discharged from the hospital, contact us as soon as possible. Early follow-up makes a real difference in recovery outcomes.
Coordinating Specialist Care
When you are seeing multiple specialists, a cardiologist, an endocrinologist, a pulmonologist, an orthopedist, the assumption is often that someone is coordinating the full picture. In practice, that coordination frequently falls short. Notes arrive late. Medication changes do not get communicated. Follow-up falls through the cracks.
Your NWPC care coordinator actively tracks specialist involvement, follows up on referrals, and makes sure the information flowing between providers is being used. You should not have to be the one holding all of that together.
Connected Across the Practice
Because care coordination operates within NWPC, your care coordinator has direct access to your full electronic health record, the same record your primary care provider, your physical therapist, and your sleep health team use. When something changes in one part of your care, your care coordinator sees it. There is no separate system to update, no fax to track down.
That shared record is what makes coordination at NWPC genuinely different from care coordination in a fragmented system.
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