Complete initial patient intake and needs assessment, in collaboration with a broader team of healthcare professionals.
Communicate findings and recommendations as well as coordinating services with other healthcare providers involved in the patient's care.
Complete scheduled home-based visits to identified at-risk members, and perform appropriate, disease-based examinations to qualify current status and associated risk.
Work closely with patients and others involved to coordinate and execute care and service planning, including medication adherence, diet, and identification of high-risk variables including falls, depression, and pain.
Provide education regarding disease management risk reduction, strategies and tactics.