Care Coordination

Care coordination and the Regional Care Team

What is a Regional Care Team?

The Jackson Care Connect Regional Care Team (RCT) offers providers a community of resources with a single point of contact for you and your patients. The RCT works closely with providers and members – through both telephonic and community-based support – to smooth the way to better care and better outcomes. Click here to view our Regional Care Team overview in PDF format.

Our purpose

With care coordination through the RCT, we will deliver
the right care, at the right time, in the right place, with the right team.

Members will have a consistent care team that will collaborate across disciplines to develop and implement a member-centric care plan through telephonic, electronic or community-based interventions to resolve identified needs and promote healthy outcomes.

The RCT is made up of care coordinators with a variety of backgrounds and experience, including:

• Nursing
• Behavioral Health
• Substance Use Disorders
• Pharmacy
• Health system navigation
• Local community resources
• And others

How the RCT is structured:

How can the RCT help my patients?

Each patient is assigned to a care team that is familiar with the patient’s history, strengths, needs and support system. The team will:

• Reduce confusion for patients by navigating them through the health care and social services system.
• Help patients get access to the right care at the right time, and make sure they stay connected to their providers.
• Reduce barriers to patient care and treatment compliance and connect them to support services.

How can the RCT help me?

Your dedicated RCT will work closely with your clinic to:

• Smooth workflows with coordination and support for primary care, behavioral health, oral health and other network providers.
• Assist with patient transitions between levels of care, such as hospital to primary care.
• Help with provider navigation, including targeted high-risk case management.
• Engage in formulary-specific medication review and communication for support of adherence.
• Address social determinants of health.

How are RCTs assigned?

RCTs are assigned based on the county the patient’s PCP clinic is in or the county where the patient lives.

When do I call the RCT?

The RCT offers care coordination and support for patients with multiple or complex needs, such as:

• Multiple chronic conditions
• High or special health care needs
• Chronic pain needs
• In-home care needs
• Daily living or social needs
• Medication review and support
• End-of-life support
• Substance use
• Behavioral health concerns

How do I make a care coordination referral?

Online: Submit a completed Care Coordination Referral form and we’ll route it to your assigned RCT.

Email: Send your completed form to ccreferral@careoregon.org

Fax: Print and send your completed form to 503-416-3676.

Collective (PreManage): If your clinic uses this online platform, check the RCT tag after searching for your patient.

Call: You can reach your RCT directly at 503-416-3742.

Download a PDF summary of this information here.