Create an individual-based care plan based on the information obtained from a comprehensive health risk assessment used to identify the enrollee’s physical, mental health, chemical dependency, and social service needs.Engaging and retaining health home enrollees in care, as well as coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee’s needs. Provide comprehensive transitional care from inpatient to other settings. Schedule appropriate followup appointments with after-care settings and ensure the individual remains in treatment. Provide Individual and family support. Engage patients in care by phone, letter, HIT and community outreach at least once per quarter. Use health information technology to link services, document care management activities, and data collection for quality indicator measurement.Provide education on preventive care.Review and upload pertinent medical/behavioral information through the RHIO Utilize all agency-based IT applications in a proficient manner. Submit timely reports of services, activities and other reports required by the supervisor and department director