Medically Driven Care Coordination for Medically Complex Children’s Waiver Participants
- Coordinate chronic and preventive medical management.
- Ensure best-practice guidelines are followed for acute illness, prevention, and safe care management.
- Coordinate specialty care services with other providers.
- Create and maintain an Emergency Medical Plan to be used by caregivers in the home.
- Facilitate participation of health-related team members in care planning.
- Provide family training regarding medical care in the home.
- Conduct family training to address disease management and, when appropriate, the child’s management of their medical condition.
- Conduct monthly physician evaluations to reassess the plan of care and ensure new needs are addressed through the care coordination process.
- Assure health, safety, and welfare as required by the 1915c waiver.
- Conduct ongoing assessment of home environment to address barriers for caring in the home.
- Maintain liaison with Department of Social Services – Foster Care.
- Re-evaluate Care Coordination Plan on an ongoing basis; provide recommendations for amendments to the plan.
- Coordinate discharge planning for participants with recommendations for termination and transfer out of the MCC Waiver as appropriate.
- Coordinate discharge planning and transition to another waiver and / or PCP / MH upon aging out of MCC Waiver.
Notice of Non-Discrimination/Language Services
If your primary language is not English, language assistance services are available for you, free of charge. Call 1-888-549-0820 (TTY 1-888-842-3620).