- Conduct comprehensive telehealth initial visits (15-20 min) for enrolled members.
- Synthesize complex medical and social histories to identify clinical priorities and risks.
- Create concise, actionable clinical plans and handoffs for Community Health Workers, LCSWs, and care navigators.
- Document findings and recommendations clearly in the EMR to guide ongoing care.
- Provide clinical guidance on escalation pathways and program workflows during the pilot.
- Build rapid clinical rapport and trust with members and caregivers.