Care Coordination Agencies

Description: Programs that develop plans for the evaluation, treatment and/or care of individuals who, because of age, illness, disability or other difficulties, need assistance in planning and arranging for services; which assess the individual's needs; coordinate the delivery of needed services; ensure that services are obtained in accordance with the case plan; and follow up and monitor progress to ensure that services are having a beneficial impact on the individual. Case management is a collaborative process characterized by communication, advocacy and resource management to promote high quality, cost-effective interventions and outcomes. (AIRS PH-1000)

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Disclaimer...
Note: Service listings do not represent a recommendation or endorsement by the Medical Home Portal staff or its sponsoring organizations; nor do they reflect any assessment of the quality or value of a listed Service.

Statewide

Organization Name: Utah Department of Health
Address: PO Box 144610
UT
Phone: 800-829-8200
Toll Free Phone: 800-829-8200
Fax: 801-584-8488
Eligibility: Utah children who have been diagnosed as having hearing loss who cannot receive a hearing aid through Medicaid or private insurance and are at or below 300 percent of the federal poverty level.
Wheelchair Accessible: Complete
Services Provided: Provides and promotes family-centered, care coordination and facilitates the development of community-based systems for children with special health care needs and their families. Direct Services provided by the University of Utah Health Care Center.
Programs include Autism System Development, Child Health Advanced Records Management (CHARM), Children's Hearing Aid Program, Critical Congenital Heart Defect (CCHD) Screening, Cytomegalovirus (CMV) Public Health Initiative, Early Hearing Detection and Intervention (EHDI), Fostering Healthy Children Program, Integrated Services Program, Kurt Oscarson Children's Organ Transplant Fund, Newborn Bloodspot (Heelstick) Screening Program, Technology Dependent Waiver, and Utah Birth Defects Network.
Provider Profiles: Lynne Nilson, Director, Bureau of Maternal and Child Health
Original Source:
Last Updated: 10/19/2017
Organization Name: Children with Special Health Care Needs (CSHCN), Utah Department of Health
Address: 44 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-584-8598
Eligibility: Foster children with special health care needs. Sliding scale based on income.
Services Provided: A program to ensure ongoing medical, dental and mental health services are provided for children in Division of Child and Family Services (DCFS) custody. This is done by maximizing quality and timeliness of health care services for the children and ensuring access to providers.

Nurses and staff from the Utah Department of Health are co-located in offices with caseworkers from DCFS. They work in partnership to coordinate the foster child's health care while in custody.
Provider Profiles: LaRene Adams, RN
Melanie Hansen, RN
Original Source:
Last Updated: 3/8/2018
Organization Name: Bureau of Maternal and Child Health (MCH), Utah Department of Health
Address: 3760 South Highland Drive
UT 84106
Phone: 801-273-2988
Toll Free Phone: 800-829-8200
Eligibility: 0 - 18 years of age, children and adolescents with special health care needs in Utah. No fee. Spanish services available.
Services Provided: Assists families of children and youth who have special health care needs with coordinated care planning, education and resources, in order for them to make informed decisions. This may include primary and special health care, behavioral health, developmental and educational programs, financial support resources and social services that meet their special needs from infancy through the transition to adulthood.
Provider Profiles: M-F 8 - 5
Eric Christensen, Program Manager
Care Coordinators

Gina Pola-Money, Director, Family-to-Family (F2F) Health Information Center
Original Source:
Last Updated: 11/16/2017
288 North 1460 West, 4th Floor
PO Box 142005
UT 84114-2005
Phone: 801-538-6113
Organization Name: Utah Department of Health
Address: 288 North 1460 West, 4th Floor
PO Box 142005
UT 84114-2005
Phone: 801-538-6113
Fax: 801-538-6387
Services Provided: A health resource for Utah's rural, multicultural and underserved communities, the Office coordinates federal, state, and local efforts aimed at improving the health of Utah's rural, medically underserved, and multicultural residents. The Office works with communities that need assistance conducting needs assessments, recruiting health care professionals, grant writing, identifying sources of funding and implementing other projects related to decreasing disparity and increasing access to primary health care.
Original Source:
Last Updated: 10/11/2017
Organization Name: EPICC Program, Bureau of Health Promotion, Utah Department of Health
Address: UT
Eligibility: Students K-12
Services Provided: School nurse care coordination involves case management, chronic disease management, direct care, nursing delegation, and student-centered care. The school nurse develops individualized healthcare plans (IHP) and emergency action plans (EAP) for those students with chronic health conditions and ensures the staff in the schools are trained on how to care for those students.
Website to provide forms for parents to download authorizing medication and self-administration.
Provider Profiles: Healthy Living through Environment, Policy & Improved Clinical Care (EPICC), UDOH
Original Source:
Last Updated: 10/24/2016
Address: 195 North 1950 West
UT 84116
Phone: 801-538-4171
Fax: 801-538-4016
Eligibility: Open to all
Services Provided: Providing children, youth, families and adults care, services and treatment to live safe, healthy and successful lives and to thrive in their homes and communities.
Original Source:
Last Updated: 3/5/2018

Bountiful, UT

Address: P.O. Box 471
Bountiful, UT 84010
Phone: 801-597-5877
Email: southdavisserviceorg@gmail.com
Eligibility: Open to the public.
Services Provided: Provides information and referral to resources for food, clothing, housing, family and child safety and support, transportation, legal assistance, foreclosure, bankruptcy, medication and medical treatment, job opportunities, job training, education opportunities, and funding to those unemployed.
Original Source:
Last Updated: 8/16/2017

Layton, UT

Organization Name: Davis Behavioral Health
Address: 934 South Main Street #8
Layton, UT 84041
Phone: 801-776-0054
Fax: 801-774-6100
Eligibility: Resident of Davis County, pregnant and using tobacco or other substances (ATOD). New mother using ATOD or currently receiving substance abuse services with Davis Behavioral Health.
Wheelchair Accessible: Entry, indoor access, and designated parking.
Services Provided: The Davis Family Advocate Program is a wraparound service of Davis Behavioral Health The program offers case management services designed to help pregnant and/or parenting patients find resources needed to maintain a substance-free lifestyle.
Original Source:
Last Updated: 1/11/2017

Logan, UT

Organization Name: Division of Services for People with Disabilities (DSPD)
Address: 115 Golf Course Road
Logan, UT 84321
Phone: 877-568-0084
Eligibility: Person must be a U.S. citizen or legal permanent resident, and a resident of the State of Utah. Eligible conditions include: Developmental disabilities (onset before age 18); brain injury (acquired after age 18); and physical disability (adults with the functional limitation of 2 limbs).
Services Provided: Provides long-term supports and services for people with disabilities so they can lead self-determined lives and participate fully in their communities. DSPD also promotes public awareness and acceptance of people with disabilities.
Original Source:
Last Updated: 10/16/2017

Midvale, UT

529 West 7300 South (9th Ave)
Midvale, UT 84047-7132
Phone: 801-569-1201
Organization Name: The Road Home
Address: 529 West 7300 South (9th Ave)
Midvale, UT 84047-7132
Phone: 801-569-1201
Email: info@theroadhome.org
Eligibility: Homeless families with children.
Services Provided: Provides emergency shelter and personalized case management for families with children to help them overcome the obstacles that have led to homelessness.
Original Source:
Last Updated: 4/17/2018

Moab, UT

1165 South Highway 191, Suite 2
Moab, UT 84532
Phone: 435-259-3738
Service Categories:
Address: 1165 South Highway 191, Suite 2
Moab, UT 84532
Phone: 435-259-3738
Service Categories:
Eligibility: 5-18 years of age.
Services Provided: Services for children 5-18 years of age. Combines the efforts of agencies which work with the youth to provide comprehensive services to young people and their families.
Original Source:
Last Updated: 12/7/2017

Murray, UT

575 East 4500 South Ste B-210
Murray, UT 84107
Phone: 801-288-4004
Service Categories:
Address: 575 East 4500 South Ste B-210
Murray, UT 84107
Phone: 801-288-4004
Fax: 801-288-4002
Service Categories:
Eligibility: Individuals who, because of age, illness, disability or other difficulties, need assistance.
Services Provided: Programs that develop plans for the evaluation, treatment and/or care; assist in planning and arranging for services; assess the individual's needs; coordinate the delivery of needed services; ensure that services are obtained in accordance with the case plan; and follow up and monitor progress to ensure that services are having a beneficial impact on the individual.
Original Source:
Last Updated: 2/28/2017

Ogden, UT

Organization Name: Midtown Community Health Centers
Address: 2240 Adams Avenue
Ogden, UT 84403
Phone: 801-393-5355
Fax: 801-394-4609
Eligibility: Open to all
Wheelchair Accessible: Complete
Services Provided: Health care coordination, case management, and prescription assistance for uninsured children, families, and adults including health education and specialty care coordination available at every Midtown Community Health Clinic location from Salt Lake City to Logan. Enrollment Specialist also available by appointment to help with navigation of Medicaid, CHIP, PCN, UPP, and Marketplace plans (ObamaCare).
Original Source:
Last Updated: 11/8/2017
Organization Name: Weber Human Services
Address: 237 26th Street
Ogden, UT 84401
Phone: 801-625-3770
Eligibility: Weber Human Services currently provides services for individuals who are eligible for Medicare or Medicaid, who reside in Weber and Morgan Counties. Weber Human Services also provides Crisis Services for all residents of Weber and Morgan Counties, and services for individuals who are civilly committed.
Wheelchair Accessible: Complete
Services Provided: Works to decrease adolescent substance abuse, reduce problem behaviors exhibited by teens, and enhance the general stability of the family by engaging and empowering families in high quality, cost-effective services.
Provider Profiles: Local mental health authority
Original Source:
Last Updated: 2/14/2017

Provo, UT

306 West Riverbend Lane
Provo, UT 84604
Phone: 801-226-5887
Address: 306 West Riverbend Lane
Provo, UT 84604
Phone: 801-226-5887
Eligibility: Accepts Medicare, Medicaid and private insurance.
Services Provided: Long-term acute care (LTAC) facility.
Original Source:
Last Updated: 7/23/2014

Salt Lake City, UT

Address: 347 South 400 East
Salt Lake City, UT 84111
Phone: 801-364-7765
Fax: 801-364-7228
Eligibility: Need valid prescription in-hand.
Wheelchair Accessible: Entry and Bathroom(s)
Services Provided: Assists and organizes low income, disabled, and minority Utahns to meet basic survival needs and to address essential issues affecting quality of life.
Original Source:
Last Updated: 4/3/2018
3690 South Main Street
Salt Lake City, UT 84115
Phone: 801-587-2096
Organization Name: University of Utah Health Care
Address: 3690 South Main Street
Salt Lake City, UT 84115
Phone: 801-587-2096
Eligibility: Children 0 - 21 years of age residing in shelter, kinship, foster care or other out-of-home placement, and those that do not have a primary healthcare provider
Services Provided: Providing comprehensive healthcare services for youth in foster care and out-of-home placements, to improve outcomes, provide continuity and facilitate coordination of care.

Satellite clinics: Christmas Box House and Cornerstone, Salt Lake Valley Detention Center
Provider Profiles: Julie Steele, DNP, ARN, FNP-C South Main Foster Program Coordinator

In partnership with the University of Utah Department of Pediatrics, College of Nursing (Fostering Healthy Children), and support from the Division of Child and Family Services.
Original Source:
Last Updated: 10/19/2017
Organization Name: Valley Behavioral Health
Address: 550 West 700 South
Salt Lake City, UT 84101
Phone: 801-537-7537
Fax: 801-363-3140
Eligibility: Individuals age 18 and older who are homeless and have a severe and persistent mental illness, inclusive of psychotic disorders.
Services Provided: Provides services for homeless individuals who are severely and persistently mentally ill (SPMI). Services include a non-traditional outpatient unit tailored to this unique population, as well as transitional and permanent housing, alcohol and drug treatment, and Shelter+ Care vouchers.
Original Source:
Last Updated: 3/13/2017
Organization Name: University Neuropsychiatric Institute (UNI), University of Utah
Address: 650 Komas Drive, Suite 200
Salt Lake City, UT 84108
Phone: 801-581-5515
Languages Spoken: Interpretive services available.
Eligibility: Children and adults. Medicaid required, no diagnosis with behavioral concerns, willingness to get primary care with HOME program.
Services Provided: The Neurobehavior HOME Program meets medical and mental needs for people with developmental disabilities. Medical home services include primary care, psychiatric evaluations, medication management, counseling services, behavior support, and case management. Experience in working with the complex medical and mental health issues often presented by people with developmental disabilities. Many of our patients have impairments in their intellectual and/or social functioning which is a result of other developmental problems such as genetic disorders, birth trauma, autism spectrum disorders, uncontrolled diabetes and brain injuries.

Autism Spectrum Disorder Clinic partner
Provider Profiles: Regular hours, plus 24/7 coverage, telemedicine available.
No waitlist for children.
Deborah Bilder, MD
Dean Weedon, MSc, Program Manager

See brief introductory video on Neurobehavior HOME Program: https://www.youtube.com/watch?v=mo8OwJIqZBo&index=8&list=PLGPZBtAtWIlWZ7RBq8HhA3u4Pm37DsZ1F
Original Source:
Last Updated: 12/6/2017
81 N Mario Capecchi Drive
Eccles Primary Children's Outpatient Services Building
Salt Lake City, UT 84113
Phone: 801-213-3599
Organization Name: Division of Pediatric Physical Medicine and Rehabilitation, University of Utah Health Care
Address: 81 N Mario Capecchi Drive
Eccles Primary Children's Outpatient Services Building
Salt Lake City, UT 84113
Phone: 801-213-3599
Eligibility: Ages 0-18 with complex chronic conditions associated with disabilities; ages 18 - 21 generally seen for transitional conditions, including spasticity and pump management.
Services Provided: The Comprehensive Care Program delivers high quality, coordinated and family-centered pediatric health care for children with complex chronic conditions associated with disabilities, technology dependencies, multiple subspecialists, and frequent hospitalizations. Team-based care includes complex care coordination, co-management with specialists, and education and advocacy for each child and family.
Provider Profiles: Nancy Murphy, MD, Chief, Pediatrics, Physical Medicine and Rehabilitation
Justin Alvey, MD, Pediatrics
Shane Dangerfield, MD, Pediatrics, Rehabilitation

PCH Outpatient Services at Riverton and South Davis Community Hospital.
Pediatric Rehabilitation also in Division of Pediatrics Physical Medicine and Rehabilitation, University of Utah

For appointments or referrals, call 801 213-3599 and choose option #1, then ask to speak with the Referral Team. This will give you the most comprehensive and coordinated experience.
Original Source:
Last Updated: 2/13/2017
Organization Name: Primary Children's Hospital, University of Utah
Address: 100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-662-4700
Wheelchair Accessible: Complete
Services Provided: Pediatric Hematology and Oncology division evaluates and treats many blood disorders and cancers. Monthly support group. Specialty clinics for childhood leukemia, brain tumors, sarcomas, solid tumors, and histiocytosis, bleeding and clotting disorders;
Specialty comprehensive clinics for children and adults with hemophilia.
Original Source:
Last Updated: 3/30/2016
100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-213-3599
Organization Name: Primary Children’s Hospital and University of Utah Medical Group
Address: 100 N Mario Capecchi Drive
Salt Lake City, UT 84113
Phone: 801-213-3599
Eligibility: 3 chronic conditions, high utilization, a number of specialists. Most health insurance. Referrals, inpatient, clinics.
Services Provided: Pediatric Specialty Services (PSS) is a collaboration between Primary Children’s Hospital (PCH) and the University of Utah Medical Group’s (UUMG) Pediatric and Pediatric subspecialty providers to align the organizations in developing value-based payment and care delivery models to manage services for children who need specialty and tertiary care.
Provider Profiles: Dr. Colleen Marty
Christy Aubert PA
comprehensive care clinic 801-213-3599
Original Source:
Last Updated: 4/3/2018
1307 South 900 West
Salt Lake City, UT 84104
Phone: 801-977-1122
Address: 1307 South 900 West
Salt Lake City, UT 84104
Phone: 801-977-1122
Toll Free Phone: 800-796-2444
Fax: 801-355-1798
Eligibility: Call or visit website www.slcap.org
Services Provided: Provides employment assistance, weatherization, food assistance, housing assistance, Head Start programs, and utility assistance. Supports a family's progress to self sufficiency with a goal to promptly stabilize a family in crisis and avoid the long-term consequences of costly dependency. Also advocates for public policy changes.
Original Source:
Last Updated: 3/13/2018
Organization Name: Division of Services for People with Disabilities
Address: 195 North 1950 West
Salt Lake City, UT 84116
Phone: 877-568-0084
Fax: 801-538-4279
Eligibility: Children and adults, a U.S. citizen or legal permanent resident, and a resident of the State of Utah. Eligible for services if they have qualifying disabilities in one of four areas: intellectual disabilities or related conditions; Acquired Brain Injury (ABI); physical disabilities; autism.
Services Provided: The Division of Services for People with Disabilities (DSPD) serves children and adults who have intellectual disabilities, physical disabilities, brain injuries, and autism. Home and community-based services including: community living, day services, supported employment services, and support for people with disabilities and their families. Services are uniquely tailored to each person and family and are designed to allow persons with disabilities to lead self-determined lives and be full participants in their communities.
Disabilities in one of four areas: intellectual disabilities or related conditions; Acquired Brain Injury (ABI); physical disabilities; autism.

Services which DSPD may be able to provide include:
Respite Care
Service Brokering
Family Skill Building and Preservation Classes
Supported Employment, Supported Living and Transportation Services.
Provider Profiles: There is a waiting list dependent on funding by the State Legislature.
Original Source:
Last Updated: 4/4/2018
Address: 120 West 1300 South
Salt Lake City, UT 84115
Phone: 801-486-4877
Toll Free Phone: 866-687-4942
Fax: 801-486-9943
Email: info@iwic.org
Eligibility: Programs are designed for American Indians/Alaskan Natives.
Wheelchair Accessible: Complete
Services Provided: Provides services that identify critical health risks and educate clients concerning preventive care, encouraging better overall health, well-being and enjoyment of life within the American Indian community.
Original Source:
Last Updated: 4/24/2018

St. George, UT

Organization Name: Division of Services for People with Disabilities (DSPD)
Address: 377 East Riverside Dr Bldg B Ste A
St. George, UT 84790
Phone: 435-674-3961
Toll Free Phone: 877-568-0084
Fax: 435-674-3939
Eligibility: U.S. citizen or legal permanent resident, and a resident of the State of Utah. children and adults who have intellectual disabilities, physical disabilities, brain injuries, and autism.
Services Provided: Provides long-term supports and services for people with disabilities so they can lead self-determined lives and participate fully in their communities. DSPD also promotes public awareness and acceptance of people with disabilities.
Original Source:
Last Updated: 8/18/2016

Tropic, UT

Address: PO Box 207
Tropic, UT 84776
Phone: 435-676-2599
Fax: 866-897-7322
Email: Tracyj@nffutah.org
Eligibility: Parents with referral for program from DCFS. Other parents by request.
Wheelchair Accessible: Varies By Location
Services Provided: A service organization for at risk children in rural central Utah, providing Family Resource Facilitating, Peer Parenting, Supported Employment, After-school Programs. Provides support to parents and youth with complex needs, through education, advocacy, training and peer to peer support. The Family Academy provides training on topics including school issues, communication, mediation, family teaming, family culture, agency support and mandates, as well as services and supports available in their local community.
Participates in the Family Resource Facilitator Project, employing highly trained parent resource facilitators.
Original Source:
Last Updated: 5/3/2018