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Care coordination promotes integration and cooperation among service providers and reinforces treatment strategies that support members’ motivation to better understand and actively self-manage his or her health conditions. Activities are conducted by care coordinators with members for their identified supports, medical and behavioral health providers, and community providers. Care coordinated will implement the individualized Service Plan, and coordinate appropriate linkages, referrals, and follow-ups. Care coordinators’ activities include, but are not limited to:

  • Outreach and engagement of Medicaid members;
  • Communication with members, their family, other providers and team members, including a visits to address health and safety concerns;
  • Ensuring members have access to pharmacological support, age-appropriate resiliency and recovery services, and natural and community supports;
  • Ensuring services are integrated and compatible as identified in the Service Plan;
  • Coordinating primary, specialty, and transitional health care from Emergency Department;
  • Making referrals, assisting in scheduling appointments, and conducting follow-up monitoring;
  • Developing self-management plans with members;
  • Delivering health education specific to a member’s chronic conditions;
  • Conducting a face-to-face in-home visit within two weeks of a Nursing Facility determination;
  • Coordinating with the MCO care coordinator when a member has a Nursing Facility determination.

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