Care Coordination Agencies

Suggest a New Provider

Description: Programs that develop plans for the evaluation, treatment and/or care of individuals who, because of age, illness, disability or other difficulties, need assistance in planning and arranging for services; which assess the individual's needs; coordinate the delivery of needed services; ensure that services are obtained in accordance with the case plan; and follow up and monitor progress to ensure that services are having a beneficial impact on the individual. (AIRS PH-1000)

If you know of a Service that should be listed but isn't, please Suggest a New Provider. If you find errors in a listing, please let us know by using the "Suggest an Edit" form on the provider's detail page.
Disclaimer...
Note: Service listings do not represent a recommendation or endorsement by the Medical Home Portal staff or its sponsoring organizations; nor do they reflect any assessment of the quality or value of a listed Service.

Statewide (5)

Layton (1)

Logan (1)

Moab (1)

Murray (1)

Ogden (2)

Provo (1)

Salt Lake City (9)

St. George (1)

Tropic (1)

Statewide

Children with Special Health Care Needs (CSHCN), Utah Department of Health

PO Box 144610
Salt Lake City, UT 84114-4610
Phone: 801-584-8226

Service Categories:

www.health.utah.gov/cshcn/

Organization Name: Utah Department of Health

Address: PO Box 144610
Salt Lake City, UT 84114-4610

Phone: 801-584-8226

Toll Free Phone: 800-961-4226

Fax: 801-584-8488

Service Categories:

URL: http://www.health.utah.gov/cshcn/

Eligibility: Automatically qualify if have documented medical diagnosis that meets criteria.

Wheelchair Accessible: Complete

Services Provided: Provides and promotes family-centered, care coordination and facilitates the development of community-based systems for children with special health care needs and their families. Direct Services provided by the University of Utah Health Care Center.
Programs include Autism System Development, Child Health Advanced Records Management (CHARM), Children's Hearing Aid Program, Critical Congenital Heart Defect (CCHD) Screening, Cytomegalovirus (CMV) Public Health Initiative, Early Hearing Detection and Intervention (EHDI), Fostering Healthy Children Program, Integrated Services Program, Kurt Oscarson Children's Organ Transplant Fund, Newborn Bloodspot (Heelstick) Screening Program, Technology Dependent Waiver, and Utah Birth Defects Network.

Provider Profiles: Lynne Nilson, Director, Bureau of Maternal and Child Health

Original Source:	United Way 2-1-1
Last Updated:	6/11/2019

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Fostering Healthy Children, Children with Special Health Care Needs (CSHCN), Utah Department of Health

44 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-584-8598

Service Categories:

www.health.utah.gov/cshcn/programs/fhcp.html

Organization Name: Children with Special Health Care Needs (CSHCN), Utah Department of Health

Address: 44 N Mario Capecchi Drive
Salt Lake City, UT 84113

Phone: 801-584-8598

Service Categories:

URL: http://www.health.utah.gov/cshcn/programs/fhcp.html

Eligibility: Foster children with special health care needs. Sliding scale based on income.

Services Provided: A program to ensure ongoing medical, dental and mental health services are provided for children in Division of Child and Family Services (DCFS) custody. This is done by maximizing quality and timeliness of health care services for the children and ensuring access to providers.

Nurses and staff from the Utah Department of Health are co-located in offices with caseworkers from DCFS. They work in partnership to coordinate the foster child's health care while in custody.

Provider Profiles: LaRene Adams, RN
Melanie Hansen, RN

Original Source:	MedHome Portal
Last Updated:	3/8/2018

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Integrated Services Program (ISP), Bureau of Maternal and Child Health (MCH), Utah Department of Health

3760 South Highland Drive
UT 84106
Phone: 801-273-2988

Service Categories:

health.utah.gov/cshcn/programs/integratesrvs.html

Organization Name: Bureau of Maternal and Child Health (MCH), Utah Department of Health

Address: 3760 South Highland Drive
UT 84106

Phone: 801-273-2988

Toll Free Phone: 800-829-8200

Service Categories:

URL: https://health.utah.gov/cshcn/programs/integratesrvs.html

Languages Spoken: Spanish services available.

Eligibility: 0 - 18 years of age, children and adolescents with special health care needs in Utah. No fee.

Services Provided: Assists families of children and youth who have special health care needs with coordinated care planning, education and resources, in order for them to make informed decisions. This may include primary and special health care, behavioral health, developmental and educational programs, financial support resources and social services that meet their special needs from infancy through the transition to adulthood.

Provider Profiles: M-F 8 - 5
Eric Christensen, Program Manager
Care Coordinators

Gina Pola-Money, Director, Family-to-Family (F2F) Health Information Center

Original Source:	MedHome Portal
Last Updated:	12/11/2018

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Office of Primary Care and Rural Health, Utah Department of Health

288 North 1460 West, 4th Floor
PO Box 142005
UT 84114-2005
Phone: 801-538-6113

Service Categories:

health.utah.gov/primarycare/

Organization Name: Utah Department of Health

Address: 288 North 1460 West, 4th Floor
PO Box 142005
UT 84114-2005

Phone: 801-538-6113

Fax: 801-538-6387

Service Categories:

URL: http://health.utah.gov/primarycare/

Services Provided: A health resource for Utah's rural, multicultural and underserved communities, the Office coordinates federal, state, and local efforts aimed at improving the health of Utah's rural, medically underserved, and multicultural residents. The Office works with communities that need assistance conducting needs assessments, recruiting health care professionals, grant writing, identifying sources of funding and implementing other projects related to decreasing disparity and increasing access to primary health care.

Original Source:	MedHome Portal
Last Updated:	10/23/2018

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School Nurses Care Coordination, EPICC Program, Bureau of Health Promotion, Utah Department of Health

UT

Service Categories:

choosehealth.utah.gov/prek-12/school-nurses.php

Organization Name: EPICC Program, Bureau of Health Promotion, Utah Department of Health

Address: UT

Service Categories:

URL: http://choosehealth.utah.gov/prek-12/school-nurses.php

Eligibility: Students K-12

Services Provided: School nurse care coordination involves case management, chronic disease management, direct care, nursing delegation, and student-centered care. The school nurse develops individualized healthcare plans (IHP) and emergency action plans (EAP) for those students with chronic health conditions and ensures the staff in the schools are trained on how to care for those students.
Website to provide forms for parents to download authorizing medication and self-administration.

Provider Profiles: Healthy Living through Environment, Policy & Improved Clinical Care (EPICC), UDOH

Original Source:	MedHome Portal
Last Updated:	10/23/2018

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Layton, UT

Davis Family Advocate Program, Davis Behavioral Health

934 South Main Street Unit 8
Layton, UT 84041
Phone: 801-776-0054

Service Categories:

www.dbhutah.org

Organization Name: Davis Behavioral Health

Address: 934 South Main Street Unit 8
Layton, UT 84041

Phone: 801-776-0054

Fax: 801-774-6100

Service Categories:

URL: http://www.dbhutah.org

Eligibility: Resident of Davis County, pregnant and using tobacco or other substances (ATOD). New mother using ATOD or currently receiving substance abuse services with Davis Behavioral Health.

Wheelchair Accessible: Entry, indoor access, and designated parking.

Services Provided: The Davis Family Advocate Program is a wraparound service of Davis Behavioral Health The program offers case management services designed to help pregnant and/or parenting patients find resources needed to maintain a substance-free lifestyle.

Original Source:	MedHome Portal
Last Updated:	4/8/2019

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Logan, UT

Services for People with Disabilities - Logan, Division of Services for People with Disabilities (DSPD)

115 Golf Course Road
Logan, UT 84321
Phone: 877-568-0084

Service Categories:

www.dspd.utah.gov

Organization Name: Division of Services for People with Disabilities (DSPD)

Address: 115 Golf Course Road
Logan, UT 84321

Phone: 877-568-0084

Service Categories:

URL: http://www.dspd.utah.gov

Eligibility: Person must be a U.S. citizen or legal permanent resident, and a resident of the State of Utah. Eligible conditions include: Developmental disabilities (onset before age 18); brain injury (acquired after age 18); and physical disability (adults with the functional limitation of 2 limbs).

Services Provided: Provides long-term supports and services for people with disabilities so they can lead self-determined lives and participate fully in their communities. DSPD also promotes public awareness and acceptance of people with disabilities.

Original Source:	MedHome Portal
Last Updated:	10/16/2017

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Moab, UT

Local Interagency Council

1165 South Highway 191, Suite 2
Moab, UT 84532
Phone: 435-259-3738

Service Categories:

Address: 1165 South Highway 191, Suite 2
Moab, UT 84532

Phone: 435-259-3738

Service Categories:

Eligibility: 5-18 years of age.

Services Provided: Services for children 5-18 years of age. Combines the efforts of agencies which work with the youth to provide comprehensive services to young people and their families.

Original Source:	MedHome Portal
Last Updated:	12/7/2017

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Murray, UT

Eldercare Consult Inc

575 East 4500 South Ste B-210
Murray, UT 84107
Phone: 801-288-4004

Service Categories:

www.eldercareconsult.com

Address: 575 East 4500 South Ste B-210
Murray, UT 84107

Phone: 801-288-4004

Fax: 801-288-4002

Service Categories:

URL: http://www.eldercareconsult.com

Eligibility: Individuals who, because of age, illness, disability or other difficulties, need assistance.

Services Provided: Programs that develop plans for the evaluation, treatment and/or care; assist in planning and arranging for services; assess the individual's needs; coordinate the delivery of needed services; ensure that services are obtained in accordance with the case plan; and follow up and monitor progress to ensure that services are having a beneficial impact on the individual.

Original Source:	MedHome Portal
Last Updated:	2/28/2017

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Ogden, UT

Health Access Team, Midtown Community Health Centers

2240 Adams Avenue
Ogden, UT 84403
Phone: 801-393-5355

Service Categories:

midtownchc.org

Organization Name: Midtown Community Health Centers

Address: 2240 Adams Avenue
Ogden, UT 84403

Phone: 801-393-5355

Fax: 801-394-4609

Service Categories:

URL: http://midtownchc.org

Eligibility: Open to all

Wheelchair Accessible: Complete

Services Provided: Health care coordination, case management, and prescription assistance for uninsured children, families, and adults including health education and specialty care coordination available at every Midtown Community Health Clinic location from Salt Lake City to Logan. Enrollment Specialist also available by appointment to help with navigation of Medicaid, CHIP, PCN, UPP, and Marketplace plans (ObamaCare).

Original Source:	MedHome Portal
Last Updated:	11/8/2017

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Youth Futures - Ogden

2760 Adams Avenue
Ogden, UT 84403
Phone: 801-528-1214

Service Categories:

yfut.org

Address: 2760 Adams Avenue
Ogden, UT 84403

Phone: 801-528-1214

Text: 385-405-9460

Service Categories:

URL: http://yfut.org

Eligibility: Youth in need ages 12 - 18

Services Provided: Provides safe shelter and collaborative resources to homeless, unaccompanied, runaway and at-risk youth in Northern Utah. Offers 14 temporary overnight shelter beds and day-time drop-in services to youth. Youth receive intensive case management to assist them in becoming either re-united with family or able to be self-sufficient and contributing members of our community.

Original Source:	United Way 2-1-1
Last Updated:	6/12/2019

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Provo, UT

Utah Valley Specialty Hospital

306 West Riverbend Lane
Provo, UT 84604
Phone: 801-226-5887

Service Categories:

www.ernesthealth.com

Address: 306 West Riverbend Lane
Provo, UT 84604

Phone: 801-226-5887

Service Categories:

URL: http://www.ernesthealth.com

Eligibility: Accepts Medicare, Medicaid and private insurance.

Services Provided: Long-term acute care (LTAC) facility.

Original Source:	MedHome Portal
Last Updated:	7/23/2014

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Salt Lake City, UT

Connector Service Program, Pediatric Specialty Services, Primary Children's Hospital and University of Utah Medical Group

100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-662-6721

Service Categories:

Organization Name: Primary Children's Hospital and University of Utah Medical Group

Address: 100 N Mario Capecchi Drive
Salt Lake City, UT 84113

Phone: 801-662-6721

Service Categories:

Email: PCHICCTReferral@imail.org

Eligibility: Available for children with multiple, complex chronic illnesses. A medical team evaluates kids ages 0 to 17 for program enrollment. Any insurance provider accepted. Referrals welcome. Salt Lake County, southern portion of Davis County.

Wheelchair Accessible: yes

Services Provided: Connector Service assists patients and families with scheduling and support services, including home visits by a registered nurse. Three or more chronic illnesses, such as: cerebral palsy, neurologic impairments, feeding issues, or vision/hearing impairment. A multi-disciplinary team assists children who have multiple, complex chronic illnesses. Interventions, including home visitation, help support the family so children can grow healthy in their home environments. Facilitating communication among providers is an essential objective. Shared Plan of Care.

Provider Profiles: A University of Utah continuing formal research study.
Dr. Colleen Marty, Pediatrician
Christine Aubert, PA-C Physical Medicine and Rehabilitation
Karine Romero, RN, Care Manager
Sommon Ameri, Transitionist
Comprehensive Care Clinic 801-213-3599

Any pediatric specialty except: active Hematology/Oncology, Cystic Fibrosis, Spina Bifida, Transplant, or Neurobehavior Home Clinic

Original Source:	MedHome Portal
Last Updated:	12/4/2018

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Crossroads Urban Center

347 South 400 East
Salt Lake City, UT 84111
Phone: 888-747-8482

Service Categories:

www.crossroadsurbancenter.org/

Address: 347 South 400 East
Salt Lake City, UT 84111

Phone: 888-747-8482

Fax: 801-364-7228

Service Categories:

URL: https://www.crossroadsurbancenter.org/

Eligibility: Individuals and families in need of food assistance for Thanksgiving.

Wheelchair Accessible: Entry and Bathroom(s)

Services Provided: Assists and organizes low income, disabled, and minority Utahns to meet basic survival needs and to address essential issues affecting quality of life.

Original Source:	United Way 2-1-1
Last Updated:	7/9/2019

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Foster Health Care Program, University of Utah Health

3690 South Main Street
Salt Lake City, UT 84115
Phone: 801-587-2096

Service Categories:

Organization Name: University of Utah Health

Address: 3690 South Main Street
Salt Lake City, UT 84115

Phone: 801-587-2096

Service Categories:

Eligibility: Children 0 - 21 years of age residing in shelter, kinship, foster care or other out-of-home placement, and those that do not have a primary healthcare provider

Services Provided: Providing comprehensive healthcare services for youth in foster care and out-of-home placements, to improve outcomes, provide continuity and facilitate coordination of care.

Satellite clinics: Christmas Box House and Cornerstone, Salt Lake Valley Detention Center

Provider Profiles: Julie Steele, DNP, ARN, FNP-C South Main Foster Program Coordinator

In partnership with the University of Utah Department of Pediatrics, College of Nursing (Fostering Healthy Children), and support from the Division of Child and Family Services.

Original Source:	MedHome Portal
Last Updated:	8/29/2018

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Homeless Services, Valley Behavioral Health

550 West 700 South
Salt Lake City, UT 84101
Phone: 801-537-7537

Service Categories:

www.valleycares.com/

Organization Name: Valley Behavioral Health

Address: 550 West 700 South
Salt Lake City, UT 84101

Phone: 801-537-7537

Fax: 801-363-3140

Service Categories:

URL: http://www.valleycares.com/

Eligibility: Individuals age 18 and older who are homeless and have a severe and persistent mental illness, inclusive of psychotic disorders.

Services Provided: Provides services for homeless individuals who are severely and persistently mentally ill (SPMI). Services include a non-traditional outpatient unit tailored to this unique population, as well as transitional and permanent housing, alcohol and drug treatment, and Shelter+ Care vouchers.

Original Source:	MedHome Portal
Last Updated:	3/13/2017

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Neurobehavior HOME Program, University Neuropsychiatric Institute (UNI), University of Utah

650 Komas Drive, Suite 200
Salt Lake City, UT 84108
Phone: 801-581-5515

Service Categories:

healthcare.utah.edu/uni/programs/home/

Organization Name: University Neuropsychiatric Institute (UNI), University of Utah

Address: 650 Komas Drive, Suite 200
Salt Lake City, UT 84108

Phone: 801-581-5515

Service Categories:

Email: dean.weedon@hsc.utah.edu

URL: https://healthcare.utah.edu/uni/programs/home/

Map URL: http://healthcare.utah.edu/home/directions.html

Languages Spoken: Interpretive services available.

Eligibility: Children and adults. Medicaid required, behavioral concerns on a limited basis, willingness to get primary care with HOME program.

Services Provided: The Neurobehavior HOME Program meets medical and mental needs for people with developmental disabilities. Medical home services include primary care, psychiatric evaluations, medication management, counseling services, behavior support, and case management. Experience in working with the complex medical and mental health issues often presented by people with developmental disabilities. Many of our patients have impairments in their intellectual and/or social functioning which is a result of other developmental problems such as genetic disorders, birth trauma, autism spectrum disorders, uncontrolled diabetes and brain injuries. The Neurobehavior HOME program proudly serves over 1,000 people of all ages with developmental disabilities.

Autism Spectrum Disorder Clinic partner

Provider Profiles: Regular hours, plus 24/7 coverage, telemedicine available.
Waitlist
Deborah Bilder, MD
Dean Weedon, MSc, Program Manager

See brief introductory video on Neurobehavior HOME Program: https://www.youtube.com/watch?v=mo8OwJIqZBo&index=8&list=PLGPZBtAtWIlWZ7RBq8HhA3u4Pm37DsZ1F

Original Source:	MedHome Portal
Last Updated:	4/10/2019

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Pediatric Comprehensive Care, University of Utah Health

81 N Mario Capecchi Drive
Eccles Primary Children's Outpatient Services Building
Salt Lake City, UT 84113
Phone: 801-213-3599

Service Categories:

healthcare.utah.edu/pediatrics/programs-services/comprehensive-care.php

Organization Name: University of Utah Health

Address: 81 N Mario Capecchi Drive
Eccles Primary Children's Outpatient Services Building
Salt Lake City, UT 84113

Phone: 801-213-3599

Toll Free Phone: 801-662-1000

Service Categories:

URL: https://healthcare.utah.edu/pediatrics/programs-services/comprehensive-care.php

Eligibility: Ages 0-21 with complex chronic conditions associated with disabilities and medical complexity, medical fragility, technology-dependencies, psychosocial complexity.

Services Provided: The Comprehensive Care Program delivers high quality, coordinated and family-centered pediatric health care for children with complex chronic conditions associated with disabilities, technology dependencies, multiple subspecialists, and frequent hospitalizations. Team-based care includes complex care coordination, co-management with specialists, and education and advocacy for each child and family.

Provider Profiles: Nancy Murphy, MD, Chief, Pediatrics, Physical Medicine and Rehabilitation
Justin Alvey, MD, Pediatrics
Shane Dangerfield, MD, Pediatrics, Rehabilitation

PCH Outpatient Services at Riverton and South Davis Community Hospital.
Pediatric Rehabilitation also in Division of Pediatrics Physical Medicine and Rehabilitation, University of Utah

For appointments or referrals, call 801 213-3599 and choose option #1, then ask to speak with the Referral Team. This will give you the most comprehensive and coordinated experience.

Original Source:	MedHome Portal
Last Updated:	5/29/2019

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Pediatric Hemophilia and Thrombophilia, Primary Children's Hospital, University of Utah

100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-662-4700

Service Categories:

healthcare.utah.edu/pediatrics/services/hematology-oncology.php

Organization Name: Primary Children's Hospital, University of Utah

Address: 100 N Mario Capecchi Drive
Salt Lake City, UT 84113

Phone: 801-662-4700

Service Categories:

URL: http://healthcare.utah.edu/pediatrics/services/hematology-oncology.php

Wheelchair Accessible: Complete

Services Provided: Pediatric Hematology and Oncology division evaluates and treats many blood disorders and cancers. Monthly support group. Specialty clinics for childhood leukemia, brain tumors, sarcomas, solid tumors, and histiocytosis, bleeding and clotting disorders;
Specialty comprehensive clinics for children and adults with hemophilia.

Original Source:	MedHome Portal
Last Updated:	3/30/2016

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Pediatric Specialty Services, Primary Children’s Hospital and University of Utah Medical Group

100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-213-3599

Service Categories:

Organization Name: Primary Children’s Hospital and University of Utah Medical Group

Address: 100 N Mario Capecchi Drive
Salt Lake City, UT 84113

Phone: 801-213-3599

Service Categories:

Eligibility: 3 chronic conditions, high utilization, a number of specialists. Most health insurance. Referrals, inpatient, clinics.

Services Provided: Pediatric Specialty Services (PSS) is a collaboration between Primary Children’s Hospital (PCH) and the University of Utah Medical Group’s (UUMG) Pediatric and Pediatric subspecialty providers to align the organizations in developing value-based payment and care delivery models to manage services for children who need specialty and tertiary care.

Provider Profiles: Dr. Colleen Marty
Christine Aubert PA-C
comprehensive care clinic 801-213-3599

Original Source:	MedHome Portal
Last Updated:	12/4/2018

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Utah Community Action

1307 South 900 West
Salt Lake City, UT 84104
Phone: 801-977-1122

Service Categories:

www.utahca.org

Address: 1307 South 900 West
Salt Lake City, UT 84104

Phone: 801-977-1122

Toll Free Phone: 800-796-2444

Fax: 801-355-1798

Service Categories:

URL: http://www.utahca.org

Eligibility: Call or visit website

Services Provided: Empowers individuals, strengthens families, and builds communities through education and self-sufficiency programs. Provides employment assistance, weatherization, food assistance, housing assistance, Head Start programs, and utility assistance. Supports a family's progress to self sufficiency with a goal to promptly stabilize a family in crisis and avoid the long-term consequences of costly dependency. Also advocates for public policy changes.

Family Shelter 801 260-4622

Original Source:	United Way 2-1-1
Last Updated:	6/6/2019

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St. George, UT

Services for People with Disabilities - St. George, Division of Services for People with Disabilities (DSPD)

377 East Riverside Dr Bldg B Ste A
St. George, UT 84790
Phone: 435-674-3961

Service Categories:

www.hsdspd.utah.gov

Organization Name: Division of Services for People with Disabilities (DSPD)

Address: 377 East Riverside Dr Bldg B Ste A
St. George, UT 84790

Phone: 435-674-3961

Toll Free Phone: 877-568-0084

Fax: 435-674-3939

Service Categories:

URL: http://www.hsdspd.utah.gov

Eligibility: U.S. citizen or legal permanent resident, and a resident of the State of Utah. children and adults who have intellectual disabilities, physical disabilities, brain injuries, and autism.

Services Provided: Provides long-term supports and services for people with disabilities so they can lead self-determined lives and participate fully in their communities. DSPD also promotes public awareness and acceptance of people with disabilities.

Original Source:	MedHome Portal
Last Updated:	10/17/2018

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Tropic, UT

New Frontiers for Families

PO Box 207
Tropic, UT 84776
Phone: 435-676-2599

Service Categories:

newfrontiersforfamilies.org

Address: PO Box 207
Tropic, UT 84776

Phone: 435-676-2599

Fax: 866-897-7322

Service Categories:

Email: Tracyj@nffutah.org

URL: http://newfrontiersforfamilies.org

Eligibility: Parents with referral for program from DCFS. Other parents by request.

Wheelchair Accessible: Varies By Location

Services Provided: A service organization for at risk children in rural central Utah, providing Family Resource Facilitating, Peer Parenting, Supported Employment, After-school Programs. Provides support to parents and youth with complex needs, through education, advocacy, training and peer to peer support. The Family Academy provides training on topics including school issues, communication, mediation, family teaming, family culture, agency support and mandates, as well as services and supports available in their local community.
Participates in the Family Resource Facilitator Project, employing highly trained parent resource facilitators.

Original Source:	MedHome Portal
Last Updated:	10/25/2018

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