North Country Care Coordination

Certificate Training Program

Fall 2016

OVERVIEW
The term care transition refers to the movement patients make between healthcare practitioners
and settings as their condition and care needs change. This program is designed to advance the
skills and knowledge of existing care coordination professionals from hospitals, the health home,
behavioral health facilities and/or other community-based settings to enhance the continuity of
care across care settings, thus helping to deliver services to improve outcomes for patients,
providers and payers.
This curriculum will better prepare professionals to work together in interdisciplinary teams
with the patient. By sharing important clinical information and expectations about their role in
the care plan, these efforts will assist regional and statewide initiatives to reduce potentially
preventable hospital admissions.

Extended Learning Center: E-114

Mondays
October 17, 2016 January 23, 2017
(No class December 26, 2016 & January 16, 2017)
5:30 8:30 p.m.
Tuition: $360
Application deadline: October 7, 2016

Course Code: CED 093 701

WHO SHOULD APPLY?
This training program is intended for current healthcare professionals from hospitals, the health
home, behavioral health facilities and/or other community-based settings.

1. All information given on the application form must be typed or neatly printed.
2. The completed application, and any subsequent correspondence, must be mailed to the
Continuing Education Division at Jefferson Community College; 1220 Coffeen Street,
Watertown, NY 13601 Attention: Todd Parody

2016 North Country Care Coordination Certificate Program

APPLICATION
Name:_________________________________________________________________________
Last
First
Middle
Other/Previous Name (which may appear on records): ________________________________

Address:_______________________________________________________________________
Number & Street
Apt. Number
______________________________________________________________________________
City
State
Zip code

Phone: cell or day number: (

Work: (

)_____________________________

Social Security Number: _________________________________________________________

Date of Birth: ___________________________ Email:__________________________________

How did you hear about the program?

______________________________________________________________________________

Educational Background
City

Dates Attended

Degree

High School

__________________________________________________________

College

__________________________________________________________
__________________________________________________________

Special Certification(s) _________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

Employment History
Present Employer___________________________________ Title: ____________________
Address

___________________________________

Dates of Employment________

Nature of Work:
_____________________________________________________________________________________
_____________________________________________________________________________________

Previous Employer___________________________________ Title: ____________________

Address ___________________________________

Dates of Employment________

Nature of Work:
_____________________________________________________________________________________
_____________________________________________________________________________________

Previous Employer___________________________________ Title: ____________________

Address ___________________________________

Dates of Employment________

Nature of Work:
_____________________________________________________________________________________
_____________________________________________________________________________________

Previous Employer___________________________________ Title: ____________________

Address ___________________________________

Dates of Employment________

Nature of Work:
_____________________________________________________________________________________
_____________________________________________________________________________________

Certificate of Information
I certify, to the best of my knowledge, that the information supplied on this application is
complete and accurate.

Applicants signature_________________________________

Date_____________

Jefferson Community College admits students without regard for race, color, creed, sex, age, religion,
national/ethnic origin, sexual orientation, disability, pregnancy or military status.

2016 Application Checklist

.
GED, high school, or college
transcripts mailed to Continuing Education
Division.