The Registered Nurse Case Manager works in conjunction with the In-Home Care Social Worker.  The Nurse Case Manager conducts an initial interview, completes a nursing assessment and with the input of the client an individual service plan is created.  In-Home Service Program develops a comprehensive individual service plan, with regular contacts though  in-home visits, telehealth, and phone calls for regular assessment of client needs and progress. The Nurse Case Manager Assists the client to implement goals, monitor service delivery to client and document all contact, follow-up activities in client file. This program could offer, limited in-home medical equipment, nutritional supplements, home-maker services, in-home mental health services, CNA services, LVNA services and RN services, Registered Dietitian services and non-emergency medical transportation.