Tahoe Forest Health System Care Coordination

Tahoe Forest Health System Care Coordination houses two main programs: Care Coordination and Health and Resource Advocates. Care Coordination bridges the gap between hospitalizations and clinic visits, supporting patients in achieving their health goals. This involves managing the care of medically and socially complex individuals across multiple healthcare providers and community organizations to promote overall wellbeing.

Care Coordinators

Care Coordinators are licensed clinical professionals who work under the indirect supervision of a Tahoe Forest Health System medical practitioner to optimize health. Their role is to assess patient needs and develop a person-centered plan of care, which may include coordination of medical care, medication reconciliation, health education, and connections to community resources. The Care Coordination team is comprised of registered nurses, social workers, and medical assistants.

Health and Resource Advocates

Health and Resource Advocates are bilingual healthcare team members who provide advocacy, connections to community resources and interpretation as needed for socially complex patients. Health and Resource Advocates also participate in community outreach events for health screening and culturally appropriate education. We are able to meet patients in the clinic, office, field or home per patient preference, in addition to monthly telephone outreaches.

Find Us

Care Coordination services

Our program helps pregnant and new moms stay healthy and feel supported—so both you and your baby can thrive.

If you have a medical condition, a complicated pregnancy, or social concerns, your provider may refer you to us for extra care and guidance. We offer special support for conditions such as gestational diabetes and perinatal mood or anxiety disorders.

Your Care Coordinator will work closely with our Lactation and Pediatric Care teams when needed. We’ll also connect you and your family to helpful community resources—like home-visiting programs, WIC, car seat safety services, child-care options, and more.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 582-3297 to speak with a Care Coordinator.

Our team of dedicated care coordinators partners with new mothers, babies, and their loved ones to help the youngest members of our community—and their families—thrive.

We work with you to create a personalized feeding plan that fits your needs and goals. Support can begin even before your baby arrives, with prenatal visits to discuss feeding options and answer questions. After birth, a Lactation Care Coordinator may visit you in the hospital to help with any complex feeding concerns.

Once you’re home, we can continue care through visits in the OB or pediatric office—or even in the comfort of your own home. We also collaborate closely with Perinatal and Pediatric Care Coordination to ensure seamless support every step of the way.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 582-3247 to speak with a Care Coordinator.

Our Pediatric Care Coordinator partners with families to make complex medical care easier to navigate. We connect you with the right doctors, specialists, and community resources so children—from birth through age 18—can grow and thrive.

Your Care Coordinator works side-by-side with pediatricians, specialists, schools, therapy programs, and local agencies to address medical needs and the social factors that influence your child’s health.

We collaborate with our Perinatal, Lactation, and Youth Behavioral Health Care Coordination programs to provide truly family-centered care.

If your child visits the Tahoe Forest Health System Emergency Department for an illness or injury, our Care Coordinator will reach out to help with follow-up appointments and ongoing resources.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 550-6745 to speak with a Care Coordinator.

At Tahoe Forest Health System, we understand that growing up can come with emotional and mental health challenges. Our Youth Behavioral Health Care Coordination program is here to support children, teens, and young adults up to age 26 who may be struggling.

Our Care Coordinator partners with youth and their families to connect them with the right care and support, including:

  • Behavioral health services
  • Medical providers
  • School and community resources
  • County and specialized services

We work closely with pediatricians, therapists, schools, and other professionals to make sure your child receives timely, coordinated, and compassionate care.

If your child or teen has visited the Tahoe Forest Health System Emergency Department for a behavioral health concern, our Care Coordinator will follow up to ensure they get the support they need.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 550-6761 to speak with a Care Coordinator.

If you live with more than one ongoing health condition, our Chronic Care Management (CCM) program is here to help you stay as healthy as possible.

Our team follows Medicare guidelines and partners with you to create a care plan that fits your life. To qualify, you simply need to have two or more chronic conditions that may increase your risk for complications and have a primary care provider at Tahoe Forest Health System.

Your CCM Care Coordinator will:

  • Work closely with your Tahoe Forest Health System doctors and any outside specialists you may need
  • Listen to your concerns and help you set health goals
  • Provide education and support for managing your conditions and medications
  • Involve your loved ones in your care if you choose

We’re here to make sure you feel supported, informed, and confident in managing your health every day.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 582-3587 to speak with a Care Coordinator.

Living with ongoing health conditions can feel overwhelming—especially when one affects your mental or emotional well-being. Our Behavioral Health Care Coordination program is here to help you stay on track and feel supported.

If you have two or more chronic conditions, and at least one is a behavioral health diagnosis, our care coordinator will:

  • Partner with your Tahoe Forest Health System primary care provider and specialists
  • Focus on both your physical and emotional health
  • Create a personalized care plan that fits your needs
  • Connect you with community resources, services, and education

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 550-6737 to speak with a Care Coordinator.

If you’re living with a neurological condition, such as Parkinson’s disease, Multiple Sclerosis, Stroke, or a Traumatic Brain Injury, our Neuro Trauma Care Coordination program is here to help you every step of the way.

Your care coordinator will:

  • Work closely with you, your loved ones, and your Tahoe Forest medical team
  • Create a care plan that supports both your medical needs and your everyday life
  • Provide guidance, education, and resources to help you stay as independent and healthy as possible

If you’ve been treated for a traumatic injury in the Tahoe Forest Emergency Department, our Neuro Trauma Care Coordinator and Care Coordination Medical Assistant will also follow up to support your recovery and long-term health goals.

We’re dedicated to making sure you feel supported—physically, emotionally, and socially—throughout your journey to better health.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 550-6715 to speak with a Care Coordinator.

Going home after a hospital stay can feel overwhelming. Our Transitional Care Management program is designed to make that transition safer and easier.
Here’s how we help:

  • Early follow-up: A TCM Care Coordinator will call you within two business days after you leave the hospital.
  • Ongoing support: We’ll check in once a week for the next three weeks to be sure your medical and in-home care are going smoothly.
  • Medication review and education: We’ll help you understand your prescriptions and answer questions so you can take them safely.
  • Team communication: We stay in touch with your doctors and care team to keep everyone on the same page.

If you need extra support after the 30-day period, your coordinator can connect you with our Chronic Care Management program for continued care.

We’re here to help you recover confidently and stay on the path to better health.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Care Coordination. Or call (530) 550-6783 to speak with a Care Coordinator.

Our Health and Resource Advocates are here to connect you—and our entire community—with the care and services you need to stay healthy. We help you find the right medical and community resources while addressing social needs that can affect your health, such as housing, food access, or transportation.

All team members are bilingual in English and Spanish, so Spanish-speaking patients receive care that is culturally sensitive and compassionate.

You can also meet our team at local events where we provide free health education and screenings. Every month we visit Sierra Community House in Truckee and Kings Beach to offer blood pressure and blood sugar checks, in addition to attending organized community events.

Whether you need guidance, resources, or just someone to point you in the right direction, we’re here to help you and your family stay well.

Appointments

Talk to your Tahoe Forest medical provider about a referral to Health and Resource Advocates. Or call (530) 550-6701 to speak with a Health & Resource Advocate.