Complex Care Medical Home



Navigator-Medical-Social Work

The Grand-Aide is a liaison between the family and the medical care team. The Grand-Aide visits the home and helps the child and family deal with medical, social program and social work as well as coordination issues. The Grand-Aide reports to an RN/APRN supervisor – and could report additionally to a social worker for non-clinical concerns.

The patients initially will not be those who are covered by Home Health skilled nursing services.

The Grand-Aide would be involved as long as the family, Grand-Aide, supervisor and physician felt beneficial (ie not time-limited).


  • Liaison with nurse supervisor for reinforcement of nurse teaching (especially understanding and adherence with the medical regimen), medication reconciliation (video with the supervisor), and early detection of symptoms (video with the supervisor).

  • May provide care and teaching in improvement in Activities of Daily living

Social Programs / Social Work

  • Help in keeping eligibility up to date (e.g. Medicaid, SNAP, WIC, Healthy Steps etc)
  • Application for medication programs such as Astra-Zeneca
  • Information on community programs, support groups (in-person and/or web), mental health counseling, after school programs, job training, summer camps, special needs exercise programs
  • Referrals (through the supervisor) – e.g. housing conditions, abuse
  • Provider care


  • “Navigation” through the system
  • Be certain patient attends all appointments
  • Appointments and testing coordinated on same day if possible
  • Obtaining DME (including vans, wheelchairs, etc)

oMay attend appointments

oMay drive if the program desires

oMay pick up occasional prescriptions

oIncluding optometry, dental