Enrollment & Assessments: Conduct initial in-home clinical assessments for prospective frail elderly participants to determine financial, medical, and environmental eligibility for the PACE (Program of All-Inclusive Care for the Elderly) model.
Level of Care (LOC) Documentation: Meticulously fill out, justify, and submit state-required Level of Care (LOC) documentation to verify nursing home-eligible criteria for prospective enrollees.
Interdisciplinary Collaboration: Coordinate findings and present clinical intake data directly to the PACE Interdisciplinary Team (IDT), including physicians, social workers, physical therapists, and dietitians, to develop introductory care plans.
Family & Community Education: Serve as the primary field liaison, educating alternative caregivers and family members on the comprehensive medical, therapy, day-center, and transportation services provided by the managed program.