- Conduct comprehensive telehealth initial visits for enrolled members (15-20 min)
- Synthesize complex medical and social histories and 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