Community Based Services
Community Resource Navigator Program
The Outer Cape Health Services Community Navigator program helps assist residents with unmet medical, behavioral health, or human service needs through collaboration with local agencies, providers, and community groups. The Navigator works closely with community agencies from referrals and service coordination to help clients in their community by building relationships and identifying support networks.
How We Can Help
- Refer and connect to community resources such as social services, mental health services, substance abuse services, homelessness/ housing assistance, medical care, and case management.
- Problem-solve barriers to access
- Assist in navigating the variety of services available
- Coordinate care
The Navigator meets clients at a safe location of their choosing, including their home, a public location, or Outer Cape Health Services at Provincetown, Wellfleet, and Harwich locations.
How to Enroll
The Community Resource Navigator program accepts residents of all Lower and Outer Cape towns regardless of insurance. Referrals for the CRN program can be made by residents themselves, family members, service providers, or community members.
Appointments can be scheduled by contacting CRNavigator@outercape.org or calling (774) 209-3222.
Recovery Services
Care Coordination
The Care Coordination Nurse Case Manager (CC RN) is part of the primary care team and directly supports OCHS’s highest risk patients in the community. In collaboration with other members of the healthcare team, the CC RN is responsible for organizing, coordinating, and providing care coordination and care management services to patients who are most at risk for health deterioration, avoidable hospital or ED visits, and/or poor outcomes. The CC RN performs primarily telephonic care management with face to face engagement in the clinic and/or home visit for some selected situations. In collaboration with the primary care team, the CC RN develops care plans to promote self-management goals, adherence to treatment plan, prevent disease exacerbation, decrease risk status, minimize hospital and ED utilization, and improve outcomes.
HIV Care
Our care centers around the belief that people with HIV and AIDS need to live fulfilling lives. Our role from the beginning is to provide information, access to services and medical care to allow patients to stay in control of their lives. Our programs are designed to respond to the people we serve and to respond to their needs, and includes both medical and psychosocial support. The team is committed to maintaining a patient centered focus ensuring that patients are engaged in their care decisions and in control of their medical and social choices.
Our HIV protocols and guidelines reflect the most recent, updated guidelines of the US. Department of Health and Human Services and the International AIDS Society, U.S.A.
We collaborate with all healthcare resources on Cape Cod including AIDS Support Group of Cape Cod, Foley House, Infectious Disease Clinical Services at Cape Cod Health Care and Beth Israel Deaconess Medical Center’s Division of Infectious Diseases.
The HIV Specialty Team includes:
- Christopher Rowley, MD, MPH – Director of HIV Services
- Bill Shay, MD – Director of HIV/Primary care
- Amy Wolf, LICSW
- Jeffrey Schaffer, RN – Program Manager, Sexual Health