-Physican orders plan of care and certifications

-Medically complex children

-Adult children who are caring for their parents and need help in managing their needs

-Need for nursing home aide, social services or rehab

-Approved by community long term care (CLTC)

-Approved by Disability Special Needs Board (DSNB)

-A face to face encounter

-Home Bound

-Experienced a recent decline in functional status

-Have a history of multiple hospital admissions or unstable medical history