Care coordination and paperwork
Service Area

Atlanta care coordination resources

Local resources and next-step checklists for adult children and family caregivers coordinating care in metro Atlanta.

Non-clinical administrative coordination. Not an emergency service.

Starting point: This page is a curated set of common resources—not a complete directory, ranking, or partner list. Please confirm details with each organization. Suggest an update.

Local snapshot

Atlanta’s health care landscape is a system-of-systems: Emory, Piedmont, Northside, Wellstar, and Grady each run multiple hospitals and specialty clinics spread across the I‑75/I‑85 connector and around I‑285. For families coordinating from out of town, “Atlanta” on a discharge paper can mean Midtown, Clifton/Decatur, Sandy Springs, Marietta, or downtown—each with different parking, check‑in workflows, and medical‑records processes. Traffic and campus layout matter: plan buffer time for Peachtree/connector congestion, and don’t assume two locations under the same brand share the same phone tree or portal settings. On the aging-support side, metro Atlanta families often start with the Area Agency on Aging screening line and then connect into county senior services (Fulton, DeKalb, Cobb) for meals, transportation, and caregiver programs. When siblings are spread across states, one shared “open loops” list and a single point person for calls makes the week‑to‑week logistics far easier.

Where to start (especially if you’re remote)

  • Collect decision-making and access paperwork: scanned copies of any healthcare proxy/POA, a signed release-of-information form when needed, and proxy access for each patient portal.
  • Create one shared “care binder” folder (digital works): current meds list, allergies, pharmacy, primary/specialists, insurance cards, and a simple one‑page contact sheet.
  • After every visit or hospitalization, ask for and save the after‑visit summary (or discharge summary) and the most current medication list—then share it with the family point person.
  • Keep an “open loops” list: pending referrals, tests to schedule, forms to complete, equipment deliveries, home health start dates, and next appointments (with the responsible person listed).
  • For unit or nurse-station contact details during a hospital stay, call the hospital’s main operator and ask to be transferred (numbers change frequently).
  • Pick a communication rhythm: a 10‑minute weekly family check‑in and one designated caller for providers reduces duplicate calls and mixed messages.
  • If someone is transitioning home, confirm the logistics early (transportation, follow‑up appointments, medication pickup, and who is present at home the first 48 hours).
Averyn can help
with the follow-through

Let an Averyn Care Navigator take on the “stuck in the middle” tasks:

  • Scheduling and rescheduling across multiple providers
  • Referral follow-up, pre-auth paperwork, and portal threads
  • Clear written updates that keep family aligned

Non-clinical administrative coordination (not medical advice, triage, or emergency monitoring).

Major health systems near Atlanta

Phone trees and campus details change—use the official directories linked below.

Hospital / health system
Emory University Hospital

Address: 1364 Clifton Road NE, Atlanta, GA 30322

Main: 404-712-2000

Official info

Hospital / health system
Northside Hospital Atlanta

Address: 1000 Johnson Ferry Road NE, Atlanta, GA 30342

Main: 404-851-8000

Official info

Hospital / health system
Grady Memorial Hospital (Grady Health System)

Address: 80 Jesse Hill Jr. Drive SE, Atlanta, GA 30303

Main: 404-616-1000

Official info

Hospital / health system
Wellstar Kennestone Hospital

Address: 677 Church Street, Marietta, GA 30060

Main: 770-793-5000

Official info

Hospital / health system
Piedmont Atlanta Hospital

Address: 1968 Peachtree Rd NW, Atlanta, GA 30309

Main: 404-605-5000

Official info

Caregiver support groups (in and around Atlanta)

Meeting times can change—confirm on the organization’s site before you go.

Caregiver support group
JF&CS Atlanta — Caregiver Support Group (Canterbury Court)

Schedule: In-person. Meets on the last Thursday of each month, 5:30–6:30 p.m., in the dining room at Canterbury Court.

Address: Canterbury Court, 3750 Peachtree Road NE, Atlanta, GA 30319

Listing is hosted on the JF&CS Atlanta events calendar; see the event page for any holiday exceptions or updates.

Details

Caregiver support group
JF&CS Atlanta — Caregiver Support Group (Town Square Innovative Adult Day)

Schedule: In-person. Meets on the first Tuesday of each month, 6:00–7:00 p.m., at Town Square Innovative Adult Day.

Address: Town Square Innovative Adult Day, 6150 Powers Ferry Rd NW, Sandy Springs, GA 30339

Listing is hosted on the JF&CS Atlanta events calendar; confirm the next meeting date on the event page before attending.

Details

Local aging supports & caregiver resources

Area Agency on Aging / benefits counseling
Area Agency on Aging (AAA) — statewide intake line (routes to local AAA)

Phone: 866-552-4464

Good starting point for metro Atlanta families seeking local aging programs, caregiver resources, and waiver intake. Ask to be routed to the Area Agency on Aging for your county/region.

Website

County senior services / information line
Fulton County Department of Senior Services — STARline

Address: Fulton County, GA (see department site for service locations)

Phone: 404-613-6000

Starting point for Fulton County senior services (including programs and referrals). Use the department site for current program details and locations.

Website

County senior services / information line
DeKalb County Senior Services — Senior Link Line

Address: DeKalb County, GA (see county site for service locations)

Phone: 770-322-2950

DeKalb County entry point for senior services and referrals; verify eligibility and service area on the county website.

Website

County senior services / care management
Cobb County Senior Services — Care Management

Address: Cobb County, GA (see county site for office details)

Phone: 770-528-5364

County care management services and resources; confirm current eligibility requirements and referral process on the county site.

Website

Long-term care ombudsman
Georgia Long-Term Care Ombudsman Program — Capitol Region Office

Address: Capitol Region (Fulton, Cobb, Douglas) — see page for details

Phone: 470-691-1301

Point of contact for questions or concerns involving nursing homes, assisted living, and other long-term care settings in the Capitol Region.

Website

Meals & nutrition support

In-home help (private pay)

Home health, therapy & human services

A few common starting points. Confirm service area and insurance details directly.

Skilled home health
Home health agencies
Rehab & therapy
PT / OT options
  • Rehab Without Walls — Georgia (home & community-based rehab)678-442-7861website
    Regional office listing includes contact information; confirm service area and referral requirements on the site.
  • Luna Physical Therapy — in-home visits (Atlanta area)866-525-3175website
    Scheduling is typically handled online or by phone; confirm availability by ZIP code.
  • Magnolia Physical Therapy & Wellness — Mobile PT/OT (Atlanta)678-343-6660website
    Mobile therapy practice; confirm service area, visit availability, and intake requirements directly.
  • KRU Mobile Physical Therapy (Atlanta)404-907-0608website
    Mobile PT practice; confirm appointment availability and service area directly.
Human services
Community support

Hospice & palliative support

Hospice
Wellstar Hospice Care at Cobb

Address: 4040 Hospital West Drive, Austell, GA 30106

Phone: 770-732-6710

Hospice program contact for the Wellstar system (Cobb/Austell area).

Website

Hospice
VITAS Healthcare — Atlanta hospice & palliative care

Phone: 404-843-6500

Local contact line for VITAS services in the Atlanta area.

Website

Hospice
Hospice Atlanta (Visiting Nurse Health System)

Phone: 404-869-3000

Program overview page includes the main phone number. Confirm current admission criteria and coverage area directly.

Website

Georgia statewide programs & hotlines

Looking for more? Visit the full state resource page: Georgia.

Help numbers

  • Georgia Division of Aging Services / Area Agency on Aging (AAA) — statewide intake line: (Aging services hotline) 866-552-4464website
    Starting point for local aging resources and waiver screening. Ask to be connected to your local Area Agency on Aging. Use the number on the member ID card when contacting insurance plans.
  • Georgia SHIP (State Health Insurance Assistance Program) — GeorgiaCares: (Medicare counseling (SHIP)) 866-552-4464website
    The SHIP page indicates callers should use the AAA number and select the SHIP option (verify the menu prompt before calling). Use the number on the member ID card when possible.
  • Georgia Healthcare Facility Regulation (HFR) — long-term care facility complaints: (Long-term care facility complaints / regulation) 800-878-6442website
    This line is for complaints involving licensed facilities (for example, nursing homes or assisted living). For non-facility situations, use APS guidance and local law enforcement as appropriate.

Official directories

Notable programs

Medicaid waiver starting point
Apply for the Elderly and Disabled Waiver Program (entry point)

Phone: 866-552-4464

The Georgia.gov page directs applicants to call the Area Agency on Aging (AAA) statewide number for screening and next steps.

Official info

Medicaid waiver starting point
Apply for Service Options Using Resources in a Community Environment (SOURCE)

Phone: 888-669-7195

The Georgia.gov page lists a statewide phone number for information and screening; verify current menu options when calling.

Official info

Medicaid waiver information
Georgia Medicaid — Waiver Programs (official overview)

Overview of waiver program options and links to program details; use the individual program pages for the most specific application steps.

Official info

See the full state page: Georgia

National programs & directories

Helpful starting points for benefits and caregiver support that apply nationwide.

National resource
Medicare (official program)

Use 1-800-MEDICARE for coverage questions, plan finder, claims, and appeals.

Phone: 800-633-4227

Official info

National resource
Eldercare Locator (ACL)

Find local Area Agencies on Aging, caregiver resources, and services by ZIP code.

Phone: 800-677-1116

Official info

National resource
211 (United Way / local social services)

Local referrals for food, housing, transportation, caregiving help, and more.

Phone: 211

Official info

National resource
988 Suicide & Crisis Lifeline

24/7 crisis support. Dial 988.

Phone: 988

Official info

National resource
Social Security Administration

Benefits, replacement cards, and general SSA services.

Phone: 800-772-1213

Official info

National resource
U.S. Department of Veterans Affairs (VA)

Main VA information line.

Phone: 800-698-2411

Official info

National resource
Alzheimer’s Association 24/7 Helpline

Support and information for dementia caregivers.

Phone: 800-272-3900

Official info

National resource
SNAP (Supplemental Nutrition Assistance Program) — State directory

SNAP is administered by states. Use the directory to find your state agency contact info.

Official info

National resource
Medicaid & CHIP — Contact your state agency

Official directory for state Medicaid agencies.

Official info

National resource
CMS (Centers for Medicare & Medicaid Services)

Federal agency overseeing Medicare, Medicaid, and related programs.

Official info

National resource
USDA National Hunger Hotline

Help finding food resources; also offers Spanish line 877-842-6273.

Phone: 866-348-6479

Official info

See the full national page: National resources

Medicare Advantage plan contacts (benefits & claims)

For plan-specific questions, the number on the member ID card is usually best. These are general member-services lines and contact pages.

Official tool
Compare plans by ZIP code

If you’re not sure which Medicare Advantage or Part D plans are available locally, Medicare’s official Plan Finder is the most reliable starting point: Medicare Plan Finder.

Georgia plans

  • UnitedHealthcare (Medicare Advantage) — member support877-596-3258contact
    For the fastest routing, use the phone number on the member ID card when available.
  • Humana (Medicare Advantage) — customer service800-457-4708contact
    For the fastest routing, use the phone number on the member ID card when available.
  • Aetna (Medicare Advantage) — member services844-979-3435contact
    For the fastest routing, use the phone number on the member ID card when available.
  • Cigna (Medicare Advantage) — customer service800-997-1654contact
    For the fastest routing, use the phone number on the member ID card when available.
  • Blue Cross Blue Shield — customer service (use member ID card)contact
    BCBS instructs members to use the customer service number on the member ID card for plan-specific support.

National starting points

  • Medicare (official program)800-633-4227contact
    Use the Plan Finder and your Medicare account for plan-level details.
  • UnitedHealthcare Medicare plans877-596-3258contact
    General Medicare member line; members can also use the number on the ID card.
  • Humana Medicare Advantage800-457-4708contact
    Customer Care; hours vary.
  • Aetna Medicare844-979-3435contact
    Member Services number published by Aetna; use the ID card number when possible.
  • Cigna Medicare800-997-1654contact
    Coverage/claims/Medicare information line; members can also use the number on their ID card.
  • Blue Cross Blue Shield (state-specific plans)contact
    BCBS customer service is state-based. For benefits/claims, call the number on the back of the member ID card or use the directory to find your local BCBS website.
  • Anthem Blue Cross Blue Shield (select states)contact
    Anthem contact info is state-specific. Members should use the number on the member ID card whenever possible.
  • SHIP (State Health Insurance Assistance Program)contact
    Free, unbiased Medicare counseling. Use the directory to find your state’s SHIP phone number.

How Averyn fits in

What we do

  • Scheduling, rescheduling, and logistics confirmation
  • Referral follow-up and “what’s the status?” persistence
  • Portal monitoring for administrative threads and document retrieval
  • Benefits questions support (where to look, what to ask, what to document)
  • Written updates that keep siblings aligned

What we don’t do

  • Medical advice, diagnosis, or triage
  • Emergency response or 24/7 monitoring
  • Clinical interpretation of labs or symptoms

This page is a non-exhaustive starting point for families coordinating care. Listings are informational and not endorsements. Contact details and availability can change—verify directly with each organization. Averyn Care provides non-clinical administrative coordination and is not an emergency service.

Last reviewed: 2026-01-11

Talk to an Averyn Care Navigator

If you’re coordinating care from across town or across the country, we can help you move the admin work forward—scheduling, referrals, portal threads, paperwork, and family updates.