Care Coordination

What is Care Coordination?
Care Coordination at Appalachian Regional Healthcare System is part of the on-going commitment we make to provide optimum quality care and service to our patients.

The care coordination team consists of Licensed Registered Nurses and Medical Social Workers. Your Care Coordinator  will work together with you, your physician and health care team to ensure optimum care for you during your stay and as you transition back into the community and health. Your Care Coordinator is your advocate and is available to assist you with any questions you may have regarding your treatment plan. Please feel free to speak freely with your care coordinator about any questions or concerns you may have.

Who is my Care Coordinator?
Each patient is assigned a care coordinator to assist them during their stay. Our care coordination team consists of licensed registered nurses and medical social workers with an average of 18 years of experience in the medical field.

You may meet your Care Coordinator in the emergency department or during the preadmission process if you are having a scheduled procedure. If not, your care coordinator will come by an meet you shortly after your admission to go over the plan of care and treatment goals that your physician has determined will best address your needs.

Your Care Coordinator will be available to answer any questions you may have, will contact your insurance company for approval of your stay and will begin the process of discussing your plans for care after your hospital stay to include any discharge planning needs you may have.

What is discharge planning?
Discharge planning is a service that your care coordinator starts as soon as possible; it may even begin prior to your admission if you are having a scheduled procedure. Discharge planning is a service that allows your care coordinator to work with you, your family, nurses, therapy team, insurance company and doctor to identify your needs and provide options for your continued care after your hospital stay.

Frequent discharge arrangements include:

Outpatient Therapy:

  • If you are ready for outpatient therapy at discharge, your physician will write the orders for the outpatient services you require. You will need to make arrangements to get to your therapy sessions, please let your care coordinator know if you do not have transportation available.

Inpatient Rehabilitation

  • Involves a stay at a specialized rehabilitation therapy center.
  • You must be able to participate in a minimum of 3 hours of intensive rehabilitation on a daily basis.
  • May be covered by insurance, but requires pre-approval and extensive clinical information that will be provided by your care coordinator.

Skilled Nursing Facility

  • Involves a stay at nursing home.
  • Less intensive than inpatient rehabilitation, but physical therapy is provided daily
  • Includes Nursing & Certified Nurse Assistant Care
  • Medicare pays for first 20 days, and it may also be covered by private insurance with prior approval.

Assisted Living

  • Includes facilities and apartments that provide daily assistance with meals, housekeeping and transportation.
  • You must be independent and require minimal assistance to be accepted.
  • Generally not covered by private insurance or Medicare and requires private payment on a monthly basis.
  • If your income is less than $1182 a month and you have less than $2000 in assets you may qualify for special assistance programs.

Special Equipment:

Durable medical equipment (DME) may be ordered by the doctor. Not all DME is covered or paid for by insurance, and may require payment from you. Durable medical equipment includes items like:

  • Walkers 
  • Bedside commodes
  • CPM machines


  • Special medication such as LovenoxR injections may be ordered by your doctor. This medication generally requires pre-authorization from your insurance company. Your care coordinator will check for insurance coverage and alert you to possible co-pays. If you do not have coverage for the medication, your care coordinator will assist you in completing paperwork for medication assistance programs.
  • The nurses at the hospital will educate you and your coach on proper injection techniques.
  • Your coach will need to administers the injections at home


  • You and your family or coach need to have a plan for your transportation after discharge from the hospital. Transportation to the skilled nursing facility, inpatient rehabilitation or home is not covered by Medicare or private insurance if you are medically stable to ride in a car.
  • Ambulance services for transport can be arranged, but these require companies require payment up front with rates starting at $400.