Coordinating Your Care

Your Care, Connected

Keeping track of different doctors, providers, and benefits can get confusing — and that’s exactly what your Care Management Team is here to handle. Coordinating care means your team keeps all the pieces of your care working together, so you don’t have to manage it alone.

Your team looks at your whole picture, not just the services HomeFirst covers, but also care covered by Medicare and Medicaid, plus support from your family and community. They make sure everyone involved in your care is working from the same plan of care.

What your team coordinates:

• The services HomeFirst covers, such as care at home, in the community and therapies
• Care covered by Medicare and Medicaid — even when HomeFirst doesn’t cover it directly, like seeing your own doctor or getting dialysis
• Support from your primary care doctor, your family, and community resources

How it works:

1. They get to know you. Your nurse assessor visits you at home to understand your health, your daily life, and what matters to you.
2. They build your care plan with you. Your care manager creates your Person-Centered Service Plan (PCSP) with you and the people you choose, such as family or other providers. You direct the plan.
3. They set everything up. Your team gets your services approved, arranges your providers, schedules appointments, and orders the supplies and equipment you need.
4. They keep your doctor in the loop. Your team stays in touch with your primary care doctor and other providers so everyone is on the same page.
5. They connect you to help more. If you need care that HomeFirst doesn’t cover, or community programs and benefits, your team helps you find and coordinate them.
6. They check in and adjust. Your team reviews your care plan regularly — usually about every six months — visits at least once a year, and updates your plan any time your needs change.

If you’re ever unsure who to call or how to get something, your Care Management Team is your starting point. Call 1-877-771-1119 (TTY: 711), 8:30 a.m. to 5:00 p.m., Monday through Friday.