Nurse Case Managers: Collaborates with providers, individuals, family representatives, and key stakeholders in the community to ensure individuals transition smoothly between care settings and receive the care ordered by their medical team. Works with the social work team when a need for community resources is identified.

Social Workers: Supports individuals and their families through consultation and education, documents goals of care that reflect an individual’s personal wishes. Assists with Medicaid/insurance benefits, provides assistance with access to community resources and when necessary assists transitions between care settings.

Care Coordinators: Works with the individual and individual’s caregivers, primary care physician, other providers, and the Family Choice clinical team to facilitate the coordination of care.