Care Coordination

Provide face to face services across all care settings of the member’s choice, including:

  • Care Management Face to face, in home visits to establish personal goals and plans of care, address provider management issues, and develop disaster preparedness plans. Medication review. Provide health and safety review and problem resolution. Assist with transitions between care settings. Work collaboratively with other community-based programs to provide a seamless system of care for the MCO members.
  • Care and Service Plan Review- Face to face, in home visits to review physical health systems, medical history, functioning (ADL/IADL), mental and cognitive abilities, social supports, environment, and financial resources (SSI, VA, HEAP, Homestead Exemption). Provide disease management education. Recommend housing modifications, DME, and service plan updates. Coordinate benefits and confirm eligibility status. Review and revise disaster preparedness plan. Update care plans.
  • Crisis Intervention – Psycho, social, and environmental problem solving (non-medical). Provide family and care giver education. Report abuse, neglect, exploitation. Resolve and report service delivery incidents.
  • Event Based Visits – Address changes in home environment, caregiver, physical/mental functional areas. Update care plans to address health and safety issues or areas of non-compliance.
  • Institution-based visits – Coordinate with facility to identify diagnosis, treatment and expected length of stay. Advocate for member in discharge planning meetings. Assist with transition home.
  • Service Management – Order and adjust services as needed. Resolve service delivery issues and ensure service plans remain person-centered.