Care Coordination Agencies

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.

UT

Statewide

PO Box 144610
Salt Lake City, UT 84114-4610
Phone: 801-584-8226
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
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
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
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
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
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
288 North 1460 West, 4th Floor
PO Box 142005
UT 84114-2005
Phone: 801-538-6113
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
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
Organization Name: EPICC Program, Bureau of Health Promotion, Utah Department of Health
Address: UT
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

Layton, UT

Organization Name: Davis Behavioral Health
Address: 934 South Main Street Unit 8
Layton, UT 84041
Phone: 801-776-0054
Fax: 801-774-6100
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

Logan, UT

Organization Name: Division of Services for People with Disabilities (DSPD)
Address: 115 Golf Course Road
Logan, UT 84321
Phone: 877-568-0084
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

Moab, UT

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

Murray, UT

575 East 4500 South Ste B-210
Murray, UT 84107
Phone: 801-288-4004
Service Categories:
Address: 575 East 4500 South Ste B-210
Murray, UT 84107
Phone: 801-288-4004
Fax: 801-288-4002
Service Categories:
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

Ogden, UT

Organization Name: Midtown Community Health Centers
Address: 2240 Adams Avenue
Ogden, UT 84403
Phone: 801-393-5355
Fax: 801-394-4609
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
2760 Adams Avenue
Ogden, UT 84403
Phone: 801-528-1214
Address: 2760 Adams Avenue
Ogden, UT 84403
Phone: 801-528-1214
Text: 385-405-9460
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

Provo, UT

306 West Riverbend Lane
Provo, UT 84604
Phone: 801-226-5887
Address: 306 West Riverbend Lane
Provo, UT 84604
Phone: 801-226-5887
Eligibility: Accepts Medicare, Medicaid and private insurance.
Services Provided: Long-term acute care (LTAC) facility.
Original Source: MedHome Portal
Last Updated: 7/23/2014

Salt Lake City, UT

100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-662-6721
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
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
347 South 400 East
Salt Lake City, UT 84111
Phone: 888-747-8482
Address: 347 South 400 East
Salt Lake City, UT 84111
Phone: 888-747-8482
Fax: 801-364-7228
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
3690 South Main Street
Salt Lake City, UT 84115
Phone: 801-587-2096
Organization Name: University of Utah Health
Address: 3690 South Main Street
Salt Lake City, UT 84115
Phone: 801-587-2096
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
Organization Name: Valley Behavioral Health
Address: 550 West 700 South
Salt Lake City, UT 84101
Phone: 801-537-7537
Toll Free Phone: 888-949-4864
Fax: 801-363-3140
Eligibility: Individuals age 18 and older who are homeless and have a severe and persistent mental illness, inclusive of psychotic disorders.
Services Provided: Clinic provides services for homeless individuals who are severely and persistently mentally ill (SPMI). Offer treatments for behavioral issues, psychiatric conditions, autism, addiction, and other health conditions. 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.
Provider Profiles: Tooele: 435 843-3520
Original Source: MedHome Portal
Last Updated: 9/11/2019
Organization Name: University Neuropsychiatric Institute (UNI), University of Utah
Address: 650 Komas Drive, Suite 200
Salt Lake City, UT 84108
Phone: 801-581-5515
Email: dean.weedon@hsc.utah.edu
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
81 N Mario Capecchi Drive
Eccles Primary Children's Outpatient Services Building
Salt Lake City, UT 84113
Phone: 801-213-3599
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
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: 9/4/2019
Organization Name: Primary Children's Hospital, University of Utah
Address: 100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-662-4700
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
100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-213-3599
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
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
1307 South 900 West
Salt Lake City, UT 84104
Phone: 801-977-1122
Address: 1307 South 900 West
Salt Lake City, UT 84104
Phone: 801-977-1122
Toll Free Phone: 800-796-2444
Fax: 801-355-1798
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

St. George, UT

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
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

Tropic, UT

Address: PO Box 207
Tropic, UT 84776
Phone: 435-676-2599
Fax: 866-897-7322
Email: Tracyj@nffutah.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

Nationwide

421 Butler Farm Road
Hampton, VA 23666
Phone: 866-512-3861
Organization Name: Patient Advocate Foundation (PAF)
Address: 421 Butler Farm Road
Hampton, VA 23666
Phone: 866-512-3861
Toll Free Phone: 800-532-5274
Fax: 757-952-0119
Eligibility: Existence of insurance coverage for pharmaceuticals (including Medicare Part D coverage). Qualifying income. Qualifying diagnosis verified by physician of conditions such as breast, lung, lymphoma, prostate, kidney, colon, pancreatic, head/neck cancers, malignant brain tumor, sarcoma, diabetes, multiple myeloma, myelodysplastic syndrome (and other pre-leukemia diseases) osteoporosis, pain, hepatitis C rheumatoid arthritis, selected autoimmune disorders and CIA/CIN.
Services Provided: Co-pay assistance for pharmaceuticals.
Includes mental retardation and developmental disabilities.

PAF also offers case management assistance, a National Financial Resource Directory (searchable by state), and financial aid funds. Small grants to patients who meet financial and medical criteria provided on first-come first served basis.
Original Source: Nationwide Suggest Providers Queue
Last Updated: 9/12/2019