Your Care Management Team — Always at Your Side
When you enroll, you are connected with a dedicated Care Management Team focused on helping you stay healthy, safe, and supported every step of the way.
Your Care Team may include
| Team Member | Role |
|---|---|
| Care Manager | Your main point of contact who helps coordinate your care, services, and support needs. |
| Assessment Nurse | A nurse who gets to know your health needs and home environment through regular home visits and health assessments to help ensure you receive the right care and services. |
| Personal Care Worker (Qualified Aide) | A trained aide who provides support in your home with everyday activities such as light housekeeping, laundry, shopping, meal preparation, bathing, dressing, grooming, walking, eating, medication reminders, and other daily needs that help you stay safe and comfortable at home. |
| Transitional Care Nurse | A team member who helps support members moving from inpatient stays or between settings or back into the community by coordinating services, identifying resources, and helping ensure a smooth and successful transition home. |
| Community Health Coach | A supportive team member who helps you better understand and manage your health by providing education, encouragement, and connections to community resources and wellness programs that support your overall well-being and independence. |
What to expect from your team:
- A monthly phone call to check in on how you’re doing, answer questions, and adjust your plan as your needs change.
- An annual home visit from your Assessment Nurse to complete a full health assessment in person. Additional home visits can be scheduled whenever your team — or you — feels one is needed.
- A Person-Centered Service Plan (PCSP) is written together with you, your care manager, family member and doctors. Your PCSP is a clear, written plan of your health goals and the services we will provide to help you meet them. It reflects your preferences, your culture, your informal supports (family and friends), and the providers you choose. Services are not planned or authorized until your care manager has met and collaborated with you.
- Coordinate with your doctor and any other providers you see, so everyone works from the same plan.
- Help with applications and renewals for Medicaid, entitlements, and other benefits you may be eligible for.
Your voice leads your care. Your PCSP is not something done to you — it is built with you. You, your family, and the people you trust are always part of the conversation.