Care Coordination Services

For patients receiving medical care at Callen-Lorde, our Care Coordination department offers assistance with obtaining benefits and entitlements. Referrals are provided for services including health insurance, financial assistance, intimate partner violence, legal assistance, housing, and other public and private resources.

Care Coordination services include:

Transgender Care Coordination

Connects patients of transgender and gender non-conforming (TGNC) experience to available resources, including culturally competent medical referrals, community resources, and legal services for assistance with name and gender marker changes. Patients are also provided with TGNC-specific health education; supportive counseling; HIV testing and counseling, assistance in obtaining identity documentation, applying for public benefits, navigating insurance and health benefits; and advocacy.

Women's Care Coordination

Assists patients in obtaining health insurance coverage for women's health services as well as navigating external social service systems such as health insurance, public assistance, mental health care, intimate partner violence, and other referrals as needed. Education and supportive counseling is provided for women with women's health related questions. Follow-up and financial assistance is also available for women in need of diagnostic tests for positive breast finds.

Supportive HIV Care Coordination

HIV Primary Care patients are eligible for assistance in navigating and obtaining HIV public and private benefits such as health insurance, financial assistance, individual and group mental health, substance use counseling, and HIV specific services. Patients are also provided with supportive counseling around issues of eligibility and entitlements as well as harm/risk reduction and crisis counseling.

Intensive HIV Care Coordination

Patients enrolled in this program receive intensive services both within the clinic and in their communities/homes around issues of treatment/illness education, treatment adherence, and case management services. Patients are connected with both a Care Coordinator and a Patient Navigator and are provided with appointment reminders and escorts, advocacy at various social service agencies, and assurance of continuity of care. Active patients are eligible to obtain transportation and child care services as needed.