CONSISTENT CARE

Care coordination, namely, interviewing patients about their medical history and current health to identify their healthcare needs and providing this medical information to doctors, patients, and community agencies; medical review, namely, assessing the medical history of patients for diagnosis and treatment purposes; [ In-home patient services, namely, rehabilitation patient care services for patients who frequent the emergency department; ] all of the foregoing using community health workers and being a community-based program that cooperates with local agencies