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Provides services to people who have advanced, chronic or life-limiting illnesses. Services include:

• In-home pain and symptom management.
• Care coordination with current healthcare team.
• Guidance with the development of the patient's individual plan of care.
• Advocacy for the patient.

Provides home health services to individuals with rehabilitation needs or chronic health conditions who are residing in their homes and are unable to access health care services in a clinical setting or could be best served at home. Skilled registered nurses provide services, including wound care, medication administration, physical assessments, monitoring vital signs, infusion therapy, catheter care, nutrition assessment, health education and home safety assessments. Social Workers provide case management, counseling and access to community resources. Home Care Aides provide assistance with home management, personal care, meal preparation and laundry.

• Have a confirmed diagnosis of a chronic disease, a life-threatening disease, or debilitating disease OR be seeking screening services related to symptoms or suspicion of a chronic, life-threatening or debilitating disease
• Be in active treatment, had treatment within the past 6 months, or going into treatment in the next 60 days
• Be a U.S. Citizen or Permanent Resident of the U.S.
• Be receiving treatment at a facility in the United States or one of its US territories

Provides Community Health Workers (CHWs) who partner with community agencies to help individuals living with chronic health conditions within underserved communities. CHWs assist clients in overcoming barriers to health, social services, education, and employment through client visits and community engagement.

Services include helping individuals understand their healthcare team's plan of care, connecting with community services, assists clients with navigating systems to get the care they need, conducts home visits, provides client education to improve health and wellness, and performs health and wellness activities in group sessions, health fairs, clinics, and other community settings.