Care Coordination

Care coordination is the work of making sure all the parts of your care — specialists, pharmacy, labs, imaging, hospital, and primary care — actually talk to each other and to you.

In most of the U.S. Healthcare system, this work falls on the patient. You're the one calling for records, chasing down test results, and explaining your medications to each new provider. That's not care — that's project management.

At Good Health NC in Knightdale, care coordination is part of every patient relationship. We:

1. Own the referral loop — we send the referral, share your records, track the appointment, and pull the specialist's notes back into your chart.
2. Reconcile medications at every visit and after every hospitalization or ER visit.
3. Follow up on every result — labs, imaging, biopsies, specialist consults — with you, in writing, through the portal.
4. Communicate with the hospital if you're admitted or seen in the ER, so we know what happened and what to do next.

Coordination touches every part of your care:

• Specialist referrals — cardiology, endocrinology, GI, neurology, ortho, derm, and more. See specialist referrals.
• Hospital and ER follow-up — discharge medication reconciliation, post-discharge appointments within 7 to 14 days, and admission record review.
• Imaging and labs — ordering, scheduling guidance, retrieving outside records, and reviewing every result with you.
• Pharmacy coordination — refill workflow, prior authorizations, and pharmacist consultation when there's a question. See medication management.
• Home health and DME — orders for home health nursing, physical therapy, durable medical equipment, and oxygen when clinically appropriate.
• Insurance authorizations — handling prior authorizations for medications, imaging, and procedures.
• Care transitions — moves between primary care, urgent care, specialty care, and hospital.

Here's what coordinated care looks like in practice at Good Health NC:

1. Every visit ends with a clear plan — what was done today, what's next, who's doing it, and when.
2. You get results in writing — abnormal results trigger a phone call from our team, not a mystery message you have to decode.
3. Specialist notes come back to us — we read them, summarize what matters, and update your plan.
4. You don't repeat the same story to five different offices — we send the right records ahead of time.
5. One number to call — when you don't know who to call, you call us.

We maintain an up-to-date problem list, medication list, and care team list in every chart. You can see all of it through your patient portal.

Every patient benefits from coordinated care, but it makes the biggest difference for:

• Patients with multiple chronic conditions — diabetes, hypertension, heart disease, COPD, kidney disease. See diabetes care and hypertension care.
• Patients on five or more medications — drug interactions and duplication are common when no one is reconciling the full list.
• Patients recently discharged from the hospital — the highest-risk window for readmission is the first 30 days.
• Older adults — especially those seeing three or more specialists.
• Patients with complex care needs — cancer survivors, transplant patients, those managing rare conditions.
• Caregivers — who are often coordinating care on behalf of a parent or spouse and need a clinical partner.

Care coordination is also tightly linked to preventive care — making sure screenings, vaccines, and follow-ups don't slip.

Contact Good Health NC's care team whenever any of these happen:

• You're discharged from a hospital or seen in an emergency room
• A specialist starts you on a new medication or changes a dose
• You get a result from another office and don't fully understand it
• A prior authorization gets denied or stalled
• You're being referred to a new specialist and want help vetting the choice
• You're seeing multiple providers and the plans don't seem to line up
• You're moving to the Triangle from another state and need records consolidated

After any hospital or ER visit, we ask all patients to schedule a follow-up with us within 7 to 14 days. That visit alone reduces readmission risk and catches medication errors.

Good Health NC was founded by our experienced PA-C clinical lead with 22 years of practice — to be a real medical home, not just another stop on your care journey. That means:

• A clinical team that knows your file — same providers, same nurses, same office
• Direct portal messaging with the clinical team, not a phone tree
• Active referral tracking — we know when you saw the specialist and what they said
• Same-day urgent care under the same roof — no fragmented care between sick visits and wellness visits
• Hospital follow-up within 7 to 14 days of every discharge

Most major commercial insurance, Medicare, and Medicare Advantage plans are expected to be accepted at opening.