Our Team consists of:
Justifies clinical eligibility for the program upon completion of Minimum Data Set (MDS) Assessment; Responsible for developing an individualized care plan; Follows the individual in the home and provides clinical counsel and education as needed.
Determines if the individual is living in a safe and suitable home with a qualified Caregiver upon completion of assessments; Available to guide and provide resources to Caregivers and Individuals in need; Responsible for making sure Caregivers and Individuals follow Care Plan developed by RN.
Community Health Worker
Assists Care Managers and Registered Nurses in fulfilling their Monthly Visit Schedules. Community Health Worker may fill in for a Level I or Level II monthly AFC visit.