Assessment & Care Plan
Assessment & Care Plan
We assign care managers to our members based on their specific service and language needs. The care manager will first make a visit to the member’s home and complete our initial assessment to get a holistic perspective of their needs and service requests. A care manager will work with our team, program director, and the member’s existing care team to create a specialized care plan.
Connections to Health Care & Other Services
Connections to Health Care & Other Services
Based on the individualized care plan and the member’s healthcare/wellness goals, care managers will connect the member to health care specialists, home health aids, specialty nurses, therapists, social workers, and social services.
Care Management Oversight
Care Management Oversight
Care managers continue to be involved in each part of the care plan and regularly check in with members to ensure their needs are being met and they are getting closer to their health and wellness goals. We continue to communicate with the member’s care team and assist them with any social service applications and documentation requirements as needed.
Our care management consists of the following services –
Comprehensive care management: by centralizing your care plan, your care manager can oversee the entire care process and ensure your wellness is being prioritized and cared for at every stage and in every department of your life.
Care coordination and health promotion: your care manager serves as your healthcare advocate in every part of your personalized plan of care.
Use of Health Information Technology (HIT) to link services: our care managers oversee the quality of the health and social services you are receiving, ensure you begin and continue to receive high-level care from every one of your doctors and service providers.
Comprehensive transitional care: achieving member wellness is our top priority, and we work with you and your full care team to ensure the next stages of your care are adequate and fulfill all your needs, if and when you are ready to end your care management services.
Member and family support: our care managers make it a priority to to include those invested in your wellness stay well informed in every aspect of your care, allowing them to contribute to the decisions in your health and wellness.
Referral to community and social supports: we aim to connect our members to the community services and social service programs they are eligible for and would benefit from.
Services include:
Integrating your health care through:
- Medical appointment management
- Medication management
- Medicaid recertification
- Coordination of discharge services
- Referrals to medical providers and specialists
- Connection to mental health services
- Connection to substance use services, inpatient & outpatient
- Access to government cell phones
- Needle Exchange Programs and SUD services
Prioritizing your housing needs by overseeing:
- Connection to heating and cooling assistance in the home
- Coordination with landlords/ housing courts
- Assistance completing housing applications
- Regular home visits to confirm living status and conditions
- Preparation for housing vouchers/ housing readiness
Connecting you to all beneficial social services, such as:
- Medicaid transportation (Access-a-Ride, Reduced Fair, Medicaid Transportation Benefit)
- Benefits and entitlements (SNAP, disability, utility bill payment, senior benefits)
- Connection to local pantries
- Immigration document completion
- Employment and vocational guidance
- Life Alert
- SSI/SSD application assistance
- Durable Medical Equipment (walker, cane, shower chair, etc.)
