li>Communicate and collaborate with other providers (e.g., specialists, respiratory therapists, nutritionists, physical therapists, home health providers, care managers, social workers, etc.) by optimizing the office-based care team to send, receive, and triage information flows among the providers.
Depending on the care management pathway followed, contact is provided daily to at least monthly to members:
home visits to evaluate home environments and family relationships, and to provide support and self-management coaching.