Fidelis Care at Home delivers Medicaid managed long term services and supports in a home setting, helping members maintain independence while receiving coordinated clinical and personal care. This overview explains how the program connects clinical oversight with in-home supports to address complex health and daily living needs.
Members receive time limited home and community based waivers designed to stabilize medical needs and enhance safety within the member’s usual environment. The model is built around a person centered plan, using scheduled visits and remote check ins to keep care consistent and measurable.
Program Structure and Key Contacts
| Role | Responsibility | Contact Method | Typical Availability |
|---|---|---|---|
| Managed Care Leader | Coordinates benefits, authorizations, and network providers | Member portal message or phone | Mon–Fri, 8am–6pm |
| Service Coordinator | Builds the care plan, schedules in‑home visits, handles changes | Phone and secure messaging | Mon–Sat, during business hours |
| Clinical Supervisor | Reviews clinical notes, validates therapy and nursing visits | Portal or scheduled call | As scheduled for care reviews |
| In‑Home Aide Agency | Delivers personal care, mobility support, and light housekeeping | Agency direct line for scheduling | Per visit schedule and on call for urgent needs |
| 24/7 On Call Nurse | Handles medical questions, medication concerns, and escalation | Dedicated phone line | 24 hours a day, 7 days a week |
Eligibility and Enrollment Requirements
Fidelis Care at Home targets Medicaid eligible adults with chronic conditions or high needs who can benefit from intensive in‑home services. Eligibility usually requires a functional limitation score, a care plan review, and documented clinical necessity for home based supports.
Enrollment begins with a referral from a primary care provider or specialist, followed by an assessment that determines whether the waiver level matches the member’s expected care intensity. Once approved, members transition into a structured service period with periodic reassessments to adjust staffing and clinical supports.
Member Experience and Daily Supports
From the first home visit, members work with a service coordinator to define routines, personal goals, and safety measures that align with their clinical needs. The care plan outlines visit frequency, therapist disciplines, and nursing check points, ensuring every support is time stamped and documented.
In‑home aides follow a detailed schedule for activities of daily living, medication prompts, and mobility assistance, while remote monitoring tools help track trends in weight, vitals, and symptom reports. Members can request schedule adjustments through their coordinator, which are then reviewed and approved by the clinical team to keep the plan current and effective.
Quality, Safety, and Clinical Oversight
Fidelis Care at Home applies standardized clinical protocols for wound care, respiratory support, and medication management, with regular audits to verify adherence. Each visit includes safety checks, such as fall risk assessments and environment scans, to reduce avoidable incidents in the home.
Members receive a multidisciplinary review at least every quarter, where nursing, therapy, and physician inputs are aligned. Action items from these reviews are tracked in the care plan, and any significant clinical change triggers a rapid response consult to stabilize the member’s condition.
Next Steps for Managing Home Based Care
- Confirm current eligibility and review the service authorization schedule with your service coordinator.
- Update your care plan with clear daily goals, mobility limits, and medication priorities.
- Set preferences for visit times, aide assignments, and communication channels with the clinical team.
- Use remote monitoring tools to log vitals and symptoms between visits, supporting timely clinical decisions.
- Schedule quarterly multidisciplinary reviews to align clinical, personal, and safety goals.
FAQ
Reader questions
How quickly can I schedule a new in‑home visit after a clinical change?
After a clinical change is documented, the service coordinator can often authorize and schedule an added visit within 24 to 48 hours, subject to staff availability and the member’s plan of care.
Can I change my in‑home aide if the current one does not meet my preferences?
Yes, members can request a reassignment through their service coordinator, who will review availability and match preferences while maintaining continuity of care and minimizing disruption to the schedule.
What happens if my doctor recommends a new therapy or equipment at home?
The clinical team reviews the recommendation, updates the care plan, and, when authorized, adds the necessary therapy visits or durable medical equipment to the service schedule with appropriate training for aides and family. Each visit starts with a brief safety screen, on call nurse contact details are provided, and local emergency contacts are listed in the member packet, ensuring rapid escalation when unexpected health events occur during in‑home care.