One connected care team
People can enter through any service. We listen to their goals, connect the right team members, and help referrals reach the next step.
The care pathway
This diagram shows how services can work together. The actual plan depends on each person’s needs, choices, eligibility, and available services.
A person may call about a physical, emotional health, HIV care, a chronic condition, or help with food and other needs. The team identifies immediate concerns and the right starting point.
The patient and care team set priorities, identify who is responsible for each next step, and coordinate information with permission.
As appropriate, the team can coordinate referrals to independent specialty providers, laboratories, pharmacies, behavioral health or recovery programs, wholistic medicine and wellness providers, and services for food, housing, transportation, and benefits. Our provider referral pool includes True Balance Integrative Health for independent wholistic care options. Our related community initiatives include WISH and Mama Gloria’s Food Pantry , LVKIP education and engagement, and Freedom Path financial education.
When permitted, the team checks whether an appointment or resource connection happened, reviews information that comes back, addresses remaining barriers, and agrees on the next follow-up.
What this looks like
A primary care visit identifies blood pressure concerns and difficulty getting nutritious food. The clinician and nursing team review treatment and monitoring; chronic disease support helps set goals. A community health worker connects the person to food resources, while care coordination supports a kidney specialist referral if indicated. The team follows up on results and access to services.
The HIV program offers education and helps connect the person to testing or treatment. If stress, transportation, or other concerns affect care, behavioral health, a community health worker, and care coordination can help. With the person’s permission, the team supports communication with outside clinicians and checks whether the referral was completed.
These examples illustrate a possible pathway; they do not describe a fixed sequence or guarantee a particular service or referral.
Our clinical teams are designed to share relevant information with appropriate safeguards and coordinate care rather than treating each health need in isolation.
HIV treatment, viral suppression, immune monitoring and HIV-related clinical decisions.
Preventive care, routine illness, chronic conditions, screening and overall health management.
Mental health assessment, counseling, emotional wellness and substance use support.
Education, navigation, outreach, follow-up and support addressing social needs.
Referral management, transitions of care and connections with community partners.
Shared decision-making, informed choices and care goals based on each person's preferences.
Start with a conversation