Visit PCP, SNF, Hospital case managers to explain ECM program and refer patients to Sowing Seeds ECM program.
Visit churches, public health, social services IHSS, to explain ECM program to refer patients.
Outreach to members to enroll, consent, and authorize services with health plan,
Assess patients in person or by phone
Develop and implement comprehensive care plans for individuals with complex medical needs
You will carry a load of 30- 60 patients per month
Coordinate with healthcare providers and community resources to ensure continuity of care
Conduct regular assessments and reassessments to monitor and evaluate the effectiveness of care plans
Collaborate with interdisciplinary teams to optimize patient outcomes and quality of care.
Provide education and support to patients and their families regarding their healthcare needs
Home visits
Accompany patients at doctor appointments (not driving patients but meet patients at the office, or joining on zoom)
Skill nursing home visits if patient is at the nursing home
Visiting primary care physician office on behalf of ECM patient