top of page

Care Coordination

The Miami Street Medicine Care Coordination program offers limited, goal-oriented healthcare coordination for our patients. A Care 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. This ensures follow-up with our patients and across fragmented care systems. 












MSM Care Coordinators deliver on the agreements and relationships that are developed on the streets. It is the heart of our program. Our Care 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. Our coordinators are trained to build long lasting connections with our friends on the street through a process that focuses on open communication, trust-building, and trauma informed care. The Care 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 Care 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 and specialty clinics

  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.


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

bottom of page