Identify and provide community service linkage

Assist enrollees with aftercare appointments

Provide subsequent member follow-up

Work with enrollees to identify gaps in care or obstacles to care and problem solve

Review IP Census each day to determine which enrollees on the census are re-admits

Go to facility meetings with treatment team to develop a successful aftercare plan

Manage the aftercare follow-up of identified high risk enrollees

Meet with community providers/facilities as company liaison to foster good rapport and relationships

Connect people with the care, pharmacy benefits, data and resources they need

Engage people in the treatment process and assist them to access the appropriate community services