Care Coordination Services | Visiting Hearts Home Care

Navigating the healthcare system is one of the most overwhelming experiences any family or individual can face. Whether you are caring for an aging loved one, managing a complex medical condition, dealing with housing instability, or simply trying to understand what services are available — the logistics of getting the right care can quickly become a full-time job.

At Visiting Hearts Home Care, our care coordination services go beyond scheduling caregivers and filing paperwork. We address the full picture of what affects a person’s health — medical needs, social circumstances, housing stability, access to benefits, and the connections between all of them. Our care coordination team serves seniors, adults with complex needs, Medicaid members, veterans, and individuals navigating difficult life circumstances across Phoenix, Mesa, Scottsdale, Chandler, and throughout Maricopa County.

We work alongside physicians, specialists, MCO case managers, hospital discharge planners, RBHA teams, and community organizations to ensure that every person we serve has a coordinated, whole-person care plan that reflects where they are and what they need — right now.

What Is Care Coordination?

Care coordination is the organized planning and management of a person’s health care and personal care needs across multiple providers, settings, and services. For seniors and adults with complex needs, care coordination is what prevents things from falling through the cracks — missed appointments, duplicated services, conflicting medications, or gaps in coverage.

At Visiting Hearts Home Care, care coordination means we are proactive, not reactive. We don’t wait for a problem to arise — we anticipate needs, communicate across your care team, and ensure your loved one’s care plan always reflects their current condition and goals. Our care coordinators serve as a single point of contact for families and individuals navigating the complex landscape of in-home care, Medicaid, VA benefits, housing, and community services in Arizona.

Care Coordination Services We Provide

  Every client relationship at Visiting Hearts Home Care begins with a comprehensive in-home care assessment. Our care coordinators visit the home to evaluate the client’s physical abilities, medical conditions, safety environment, daily routines, and personal preferences. From this assessment, we develop a detailed, individualized care plan that specifies exactly what services are needed, what schedule works best, and what outcomes we are working toward.

Care plans are living documents — updated regularly as needs change, conditions progress, or new services are added. Our care coordinators conduct regular check-ins with clients, caregivers, and family members to ensure the plan stays current and effective.

AHCCCS and ALTCS Navigation

Visiting Hearts Home Care is a credentialed provider with AHCCCS (Arizona Health Care Cost Containment System), the Arizona Medicaid program, and ALTCS (Arizona Long Term Care System), the long-term care Medicaid program for qualifying Arizona seniors. Our care coordinators help families understand whether their loved one qualifies for AHCCCS or ALTCS coverage, guide them through the application process, and work directly with case managers at AHCCCS, UnitedHealthcare Community Plan, and Banner Community Care to ensure services are authorized and covered.

• AHCCCS eligibility screening and application guidance

• ALTCS enrollment support and pre-application assessment

• Coordination with AHCCCS and ALTCS case managers

• Authorization management for covered in-home care services

• Ongoing communication with UnitedHealthcare Community Plan and Banner Community Care

VA Benefits Navigation for Veterans

Visiting Hearts Home Care is credentialed with TriWest Healthcare Alliance and the VA Community Care Network (VA CCN), making us an authorized provider of in-home care for eligible veterans in Arizona. Our care coordinators help veteran families understand and access the full range of VA benefits available to support in-home care, including the VA Aid and Attendance benefit and VA Community Care program.

• VA Aid and Attendance eligibility screening and referral

• VA Community Care Network authorization coordination with TriWest

• Coordination with Phoenix VA Medical Center and VA clinics

• Support for veterans enrolled in AHCCCS dual coverage

• Family caregiver support and Agency of Choice program guidance

Hospital-to-Home Transition Coordination

The transition from hospital or rehabilitation facility back to home is a high-risk period for seniors and adults recovering from illness or surgery. Without proper planning and follow-through, this transition often results in readmission, complications, or falls. Visiting Hearts Home Care’s care coordinators work with hospital discharge planners, social workers, and case managers to arrange in-home care services before your loved one even leaves the facility — ensuring continuity of care from day one at home.

• Pre-discharge coordination with hospital social workers and discharge planners

• Same-day or next-day in-home care setup for returning clients

• 24-hour care and overnight care arrangement for high-risk post-discharge periods

• Medication management coordination with pharmacies and physicians

• Follow-up appointment scheduling and transportation coordination

Social Determinants of Health (SDOH) Screening and Navigation

Health is about more than what happens in a doctor’s office. Research consistently shows that social factors — where a person lives, whether they have enough food, how they get to appointments, whether they feel safe at home — have as much impact on health outcomes as clinical care. At Visiting Hearts Home Care, addressing social determinants of health (SDOH) is a core part of how we coordinate care.

Our care coordinators and Community Health Workers conduct structured SDOH screenings using the PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences) assessment tool — a nationally validated screening that identifies the specific social needs affecting a person’s health and guides our coordination efforts.

SDOH Areas We Screen and Address

• Housing: Housing stability and living situation

• Food: Food security and access to nutritious meals

• Transportation: Transportation to medical appointments and essential services

• Utilities: Utility needs — heat, electricity, and water access

• Safety: Safety at home — domestic violence, elder abuse, unsafe conditions

• Social: Social connection and isolation

• Income: Income stability and employment barriers

• Health access: Access to medications and health literacy

When a screening identifies an unmet social need, our care coordinators connect clients with the appropriate resources — benefits programs, community organizations, housing services, food assistance, transportation options, and more. We document all referrals through CommunityCares, Arizona’s statewide closed-loop referral system, ensuring referrals are tracked, followed up on, and completed.

Community Health Worker (CHW) Services

Community Health Workers are trained professionals who serve as a bridge between the communities they live and work in and the health and social service systems that serve those communities. At Visiting Hearts Home Care, our Community Health team play a vital role in our care coordination model — providing culturally responsive, person-centered support to clients navigating complex health and social circumstances.

Unlike clinical care providers, Community Health Workers meet clients where they are — in their homes, in shelters, in community centers, at clinics, and wherever the client feels most comfortable. This outreach-oriented approach is especially effective for individuals who face barriers to traditional health care, including language barriers, past trauma, or lack of transportation.

What Our Community Health Workers Do

• Conduct outreach and initial engagement with members who are hard to reach or disconnected from care

• Complete SDOH  screenings and identify unmet social and health needs

• Navigate benefits eligibility — including AHCCCS, ALTCS, SSI, SSDI, SNAP, and housing assistance

• Accompany clients to medical appointments and serve as a trusted support person

• Provide health education and self-management support for chronic conditions

• Coordinate with MCO case managers, health homes, and RBHA teams

• Submit closed-loop referrals through CommunityCares and follow up on completion

• Conduct regular check-ins with high-need members to monitor health and social stability

• Support care transitions — from hospital to home, from facility to community

Our Community Health Workers are certified through the Arizona Department of Health Services (ADHS) and trained in Motivational Interviewing, Trauma-Informed Care, Cultural Competency, the Housing First model, and Health-Related Social Needs assessment.

Care Coordination for Housing Instability

Stable housing is one of the most powerful determinants of health. When a person is experiencing homelessness, facing eviction, or living in an unsafe housing situation, their ability to manage a health condition, keep appointments, maintain medications, or engage with any care plan is severely compromised. Visiting Hearts Home Care recognizes housing instability as a health concern — and we have built our care coordination services to respond to it.

For Medicaid members in Maricopa County who are experiencing housing instability, our care coordinators and Community Health Workers provide targeted support to address housing-related barriers to health — connecting members with resources, navigating systems, and ensuring that housing needs are reflected in every member’s care plan.

• SDOH screening to document and assess housing instability and related needs

• Referrals to housing assistance programs, emergency shelters, and transitional housing options in Maricopa County

• Benefits navigation — helping members access SSI, SSDI, rental assistance, and utility assistance

• Coordination with AHCCCS health plans and MCO case managers to incorporate housing needs into the integrated care plan

• Referrals through CommunityCares to vetted housing resources and community-based organizations

• Ongoing check-ins with members at risk of homelessness to identify and respond to early warning signs

Our Community Partners in Maricopa County Include

• AHCCCS Managed Care Organizations — UnitedHealthcare Community Plan, Banner Community Care, Mercy Care, Arizona Complete Health

• Regional Behavioral Health Authority (RBHA) — coordination with behavioral health case managers and care teams

• Hospital and health system discharge planning teams across the Phoenix metro

• Federally Qualified Health Centers (FQHCs) and community health centers

• Senior centers, adult day programs, and community organizations across Maricopa County

• Legal aid, elder law, and benefits enrollment organizations

• Food assistance programs — food banks, meal delivery, and SNAP enrollment support

• Transportation services — medical transportation and non-emergency transportation coordination

Caregiver Supervision and Quality Assurance

At Visiting Hearts Home Care, care coordination includes ongoing oversight of the care being delivered in the home. Our care coordinators conduct regular supervisory visits, review caregiver notes and documentation, and gather feedback from clients and family members to ensure care quality remains consistently high. When issues arise — a caregiver concern, a change in condition, a scheduling gap — our care coordinators respond quickly and decisively.

Family Communication and Support

When family members live far from their aging loved one — or simply struggle to stay on top of all the moving parts of senior care — our care coordinators serve as a trusted, proactive point of contact. We provide regular updates on your loved one’s condition and care, answer questions, and alert families promptly to any concerns. For adult children managing a parent’s care from out of state or from a busy career, our care coordination services provide the peace of mind that someone is always watching, always engaged, and always communicating.

Senior Resource Navigation in Arizona

Our care coordinators are knowledgeable about the full range of senior services and resources available in Maricopa County and across Arizona. We connect families with senior centers, adult day programs, meal delivery services, transportation options, legal and financial resources for seniors, caregiver support groups, and more — building a comprehensive support network around your loved one’s in-home care.

Care Coordination for Complex and High-Need Populations

Visiting Hearts Home Care’s care coordination model is built to serve any adult with complex needs. Our team is trained and equipped to coordinate care for individuals across a wide spectrum of circumstances, including populations that are frequently underserved by traditional home care agencies.

Adults with Serious Mental Illness (SMI)

For adults living with a Serious Mental Illness designation through AHCCCS, navigating the intersection of physical health, behavioral health, housing, and benefits is extraordinarily complex. Our care coordinators work alongside RBHA case managers and behavioral health providers to ensure that SMI members receive coordinated, consistent support across all of their care systems.

Adults Managing Chronic Conditions

For adults managing multiple chronic conditions — diabetes, COPD, heart disease, kidney disease, cancer, and others — care coordination prevents hospitalizations, emergency department visits, and costly gaps in care. Our coordinators work with physicians, specialists, and health plans to maintain continuous, integrated care plans that reflect the full complexity of each member’s health situation.

Adults Transitioning from Incarceration

Re-entry from incarceration is a high-risk period for health and social stability. Individuals leaving jails and prisons in Maricopa County often need immediate connections to Medicaid enrollment, primary care, behavioral health services, housing, and benefits — all at once. Our care coordinators assist with AHCCCS enrollment, benefits navigation, and community connections to support a successful transition.

Adults Experiencing Housing Instability or Homelessness

Our Community Health Workers conduct outreach in community settings, complete SDOH screenings, and connect members to housing resources and benefits — meeting people where they are and working toward stable housing as a foundation for better health.

Care Coordination for 24-Hour and Overnight Care Clients

Managing a 24-hour care or overnight care situation involves coordinating multiple caregivers, scheduling rotating shifts, communicating across teams, and ensuring seamless handoffs between caregivers. For families managing complex care needs, this level of coordination is beyond what most families can manage alone. Visiting Hearts Home Care’s care coordinators handle all of this on your behalf — scheduling, coverage, communication, and quality oversight for every shift, around the clock.

Why Choose Visiting Hearts Home Care for Care Coordination?

• AHCCCS and ALTCS credentialed — experienced in Medicaid care coordination across all AHCCCS programs

• TriWest / VA Community Care Network authorized for veteran care coordination

• UnitedHealthcare Community Plan and Banner Community Care credentialed and coordinating

• Community Health Worker (CHW) services — culturally responsive outreach and navigation for complex populations

• SDOH screening using the PRAPARE assessment tool — whole-person care addressing social needs alongside medical ones

• Housing instability coordination — connecting AHCCCS members to housing resources and benefits

• In-home assessment and individualized care planning

• Hospital-to-home transition support

• Proactive family communication and regular care plan updates

• Serving Phoenix, Mesa, Scottsdale, Chandler, Tempe, Glendale, Gilbert, Peoria, Surprise, Avondale, and Goodyear

•  insured, and bonded Arizona home care agency

• Available 24/7 

Visiting Hearts Home Care — Where Compassion Comes Home.

We coordinate the care. We address the needs. We show up for every person we serve.