MCCW Care Coordination

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 chronic 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.

 

 

 

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