Care coordination

Comprehensive Care Coordination at Every Step

Seamless support for your complete healthcare journey.

about care coordination

Your health journey involves multiple touchpoints.

Your health journey involves multiple touchpoints—regular checkups, specialist visits, medication management, and ongoing wellness support. Whether you need information, have questions about a topic of concern, require a virtual provider visit, or prefer to visit the clinic in person, we offer a full range of care to meet your needs. Even if you are hospitalized, we continue to communicate with your caregivers, advocating for you to ensure you feel supported and well-cared for.

OUR MISSION

How We Work

STEP 1

Understanding Your Needs

1.

Comprehensive assessment

We begin by thoroughly evaluating your current situation to identify your needs.

2.

Goal setting

Together, we establish clear and achievable goals that guide our efforts

3.

Risk evaluation

We assess potential risks to ensure your care plan is safe and effective.

STEP 2

Creating Your Care Plan

4.

Personalized strategies

Based on our assessment, we develop tailored strategies that align with your goals.

5.

Resource Alignment

We identify and align necessary resources to support your care plan.

6.

Timeline development

A clear timeline is established to track progress and milestones.

STEP 3

Ongoing Coordination

7.

Regular monitoring

Based on our assessment, we develop tailored strategies that align with your goals.

8.

Proactive adjustments

If needed, we proactively adjust the plan to meet your evolving needs better.

9.

Continuous support

Our commitment to you includes ongoing support to help you achieve your goals.

our services

What we offer

Achieving optimal health goes beyond simply attending medical appointments. Our care coordination services work alongside your primary care provider to ensure you receive comprehensive, continuous support for all your
health needs.

our services

Core Coordination Services

Health Journey Planning

Building your personalized pathway to wellness
  • Comprehensive health assessment

  • Personal health goals development

  • Risk factor identification

  • Lifestyle integration planning

Care Navigation Support

Your guide through the healthcare system
  • Provider referral management

  • Appointment coordination

  • Medical information interpretation

  • Healthcare resource connection

Continuous Health Monitoring

Proactive oversight for optimal wellness
  • Regular health check-ins

  • Condition management support

  • Prevention strategy implementation

  • Early intervention coordination

Care Navigation Support

Support Services

Medical Information Management

Keeping your health information organized
  • Health record coordination

  • Test result tracking

  • Treatment plan monitoring

  • Medical history management

Medication Management

Ensuring safe and effective treatment
  • Medication review and oversight

  • Supplement coordination

  • Renewal management

  • Side effect monitoring

Wellness Support Services

Empowering your healthy lifestyle
  • Nutrition guidance coordination

  • Mental health resource access

  • Physiotherapy support

  • Stress management support

Continuous Health Monitoring

Enhanced Services

Health Education & Advocacy

Knowledge and support when you need it
  • Medical research assistance

  • Health literacy support

  • Treatment option education

  • Patient advocacy services

Virtual Care Coordination

Healthcare access on your terms
  • Remote consultation management

  • After-hours support coordination

  • Telehealth service navigation

  • Patient advocacy services

Special Program Access

Enhanced care for specific needs
  • Travel health support

  • Women's health programs

  • Smoking cessation

  • Aesthetic and pain management

Serefin Red drop symbol

Your Integrated Care Coordination Team:

Healthcare works best when it's collaborative. Care coordination isn't managed by a single person—it's delivered by an integrated team of healthcare professionals working together to support your wellness journey. Each team member brings specialized expertise and collaborates seamlessly to ensure your care is comprehensive and consistent.

Learn more about our healthcare professionals
Serefin Red Pointer
Serefin Red layers symbol

Membership Benefits

As a member, you gain access to comprehensive health services beyond primary care. Our membership program includes all the benefits of care coordination, virtual care, after-hours support, and more, ensuring you receive continuous, high-quality care tailored to your unique needs.

From quick phone calls and requests for information to managing health concerns like dermatology issues or preparing for an upcoming trip, we are here to listen, advise, and comprehensively manage your needs, providing continuous care and guidance.

Get in touch
Serefin Red Pointer
Contact US

Start Your Wellness Journey Today.

Schedule a consultation today, join our membership program, or contact us for more information on how we can support your health journey with comprehensive care coordination.

Arrow pointing 45 degrees in Serefin pink
Get in touch
Luna, therapy dog, welcoming clients to Serefin Health Clinic