Is this the same as case management from my insurer?

It is complementary. We work alongside health plan case managers and often fill gaps they cannot.

What does veteran-directed care actually mean?

You receive a flexible budget and decide who provides your care, including hiring family members in many cases. We handle the administration.

A care manager reviewing a personalised care plan at a client's kitchen table.

Health

Care Coordination

The system is fragmented. Your care should not feel that way. A care coordinator holds the thread.

Call 757-461-9481 Ask a question

What you get

Inside Care Coordination

Care transitions
Support in the fragile thirty days after a hospital or rehab discharge, when most readmissions happen.
Veteran-directed care
Veterans manage a flexible budget and choose their own care providers, with our support.
Community care coordination
A single point of contact across health systems, housing, benefits and transportation.
Benefits screening
A check for every federal, state and local benefit you may be leaving on the table.
Family conferences
A facilitated conversation when a family is trying to make a hard decision together.

Who it is for

Older adults leaving the hospital, managing several chronic conditions, or navigating more than one agency at once. Veterans may qualify for veteran-directed care.

What it costs

Most care coordination is grant- or contract-funded at no cost to you. We will confirm before we begin.

Start today

One call reaches every program. Family members can call on someone’s behalf with their permission.

757-461-9481 Download the forms

How it works

What happens after you call

Referral or self-referral
Hospitals, doctors, family members and older adults themselves can all start this.
Whole-picture assessment
Health, home, money, food, transport, support network. Everything that actually affects an outcome.
A coordinated plan
We assemble the services, make the calls and confirm the appointments.
Follow-through
We stay in contact through the transition rather than handing over a list and hoping.