Case Coordination

The Miami Street Medicine program offers limited, goal-oriented case coordination for our patients. A Case Coordinator comes out on each street run, and during their interview with the patient, they will risk stratify and screen for medical-social needs before making an individualized service plan. 

 

 

 

 

 

 

 

 

 

Principles

 

MSM Case Coordinators deliver on the agreements and relationships that are developed on the streets. It is the heart of our program. Our Case Coordinators go on the street every week to meet the patient where they're at, hear their needs and strengths, and then take on a case file for each client. The Case Coordinator submits progress updates on each case and communicates that information to the team during our interdisciplinary sync meetings before each street run.

 

In addition to the cases which the MSM Case Coordinator picks up, there may be clients referred by our partner organizations (i.e. Camillus Health, Jackson) for our follow up on the street. This will allow other organizations to contact the program at any time to coordinate care of clients. In this case there should be a specific goal in mind by the partner organization (for example, Camillus may just want to know why a client is not showing up at health follow-ups).

What We Can Consistently Provide​:

  1. Engagement with MSM Street Team and broader DCSR Services. ​

  2.  Medical Referrals

    1. Scheduling appointments at select primary care offices, Camillus appt/walk in, DW/INB, IDEA Clinic, Jefferson Reeves, etc. 

    2. Broader PCP Network on a case-by-case basis. 

  3. Emotional Support & Information​

    1. Motivational interviewing

    2. Counseling and guidance

  4. ​Community Resource Referrals​​

  5.  J-11 Cards

    1. Connect & get document ready with Jackson Financial Assistance

  6. Prescriptions

    1. Help patients access, purchase, and refill prescriptions​

    2. Apply for PAP through pharmaceuticals for expensive drugs

    3. Pay for certain medications 

  7. IDs

    1. State ID issued by Camillus House

    2. State ID issued by DMV

    3. Social Security Card

    4. Medicaid Card

    5. Birth Certificates

  8. Various Manageable Tasks

    1. Examples include:

      1. Reading Glasses, Hygiene kits, Flashlights, Tents, Sleeping pads, etc.

PXL_20210424_154023650.jpg

Our street team tending to a wound while Case Coordinators intake a new patient for a primary care follow up.