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Continuing Care

Continuing Care is a care coordination service that contributes to better health outcomes and higher satisfaction for patients.

A Comprehensive, Physician-Directed Approach

Our Continuing Care program is physician-directed, serving as an extension of the primary care physician's practice. Once the patient is referred (or self-refers), the patient, care coordinators and physicians work together to assess and meet the patient's needs.

How the Program Works

The Continuing Care  Program is staffed by highly trained care coordinators. These nurses, social workers and assistants work closely with high-risk and rising-risk patients to promote better management of their health by:

  • Developing personalized goals and self-management improvement strategies for patients.
  • Helping patients manage and attend their appointments.
  • Assessing medication schedules, potential medication risks and patient educational needs.
  • Educating patients to better understand their situation and their treatment plan.
  • Identifying social and clinical challenges that may lead to avoidable hospital visits.
  • Coordinating a transition of care plan between hospitals and outpatient care.
  • Assessing behavioral health challenges, including substance use disorder and other mental health issues, and assisting patients with
    getting the care they need.


Continuing Care in Your Area

  Market Name Email Website Continuing Care Page
1 Arkansas Camillie Wilson [email protected] Arkansas Health Network
  Arkansas Hafeezah Brooks [email protected] Arkansas Health Network
2 Arizona Jason Kwan [email protected] Arizona Care Network
  Arizona Wayne Smith [email protected] Arizona Care Network
  Arizona Rosanna Macias [email protected] Arizona Care Network
3 North Central Arizona Yesenia Gurka [email protected] North Central Accountable Care
4 California, Merced Sarah Wilson [email protected] Central Vally Quality Care Network
5 California, Redding Sarah Wilson [email protected] North State Quality Care Network
6 California, Stockton Sarah Wilson [email protected] San Joaquin Quality Care Network
7 California, Sacramento Kathy Nipper-Johnson [email protected] Greater Sacramento Value Based Operations
  California, Sacramento Audrey Stout [email protected] Greater Sacramento Value Based Operations
  California, Woodland Alison Kemps [email protected] Greater Sacramento Value Based Operations
8 California, DHMSO Sheila Jackson [email protected] Central CA Value Based Operations
9 California, Santa Cruz Sarah Wilson [email protected] Santa Cruz Quality Care Network
10 California, Bakersfield Haley Campbell [email protected] Valley Integrated Provider Network
  California, Bakersfield Camille Olivieri-Kuehna [email protected] Valley Integrated Provider Network
11 Inland Empire Kanika Kisero [email protected] No CIN just Continuing Care Team N/A
12 Kentucky Pamela Thompson [email protected] CHI St Joseph Health Partners
13 Nebraska Kasey Malm [email protected] CHI Health Partners
  Nebraska Diane Mohatt [email protected] CHI Health Partners
  Nebraska/Iowa Elaine Adams [email protected] CHI Health Partners
14 Tennessee/Georgia Sandy Loveless [email protected] Mission Health Care Network
  Tennessee/Georgia Lisa Harrison [email protected] Mission Health Care Network
15 Texas Tracy Maddox [email protected] CHI Texas Health Network
16 Texas Corryne Wicks [email protected] CHI St Joseph Health Partners
15/16 Texas Kyle Sims [email protected] Both networks
  Texas Nadallie Lopez [email protected] Both networks
  Texas Nick Beaty [email protected] Both networks
17 Pacific Northwest LuzMarina Tejada [email protected] Rainer Health Network
18 Pacific Northwest LuzMarina Tejada [email protected] Puget Sound High Value Network
  National Trisha Misek [email protected]  
  National Brian Pew [email protected]  
  National Liz Spinella-Jones [email protected]  
  National Betsy Self [email protected]