Conduct in-home assessments including an evaluation of past medical history, review of systems, medication reconciliation, vital signs, and comprehensive physical exam Perform evidence-based practice screenings including point of care testing (as appropriate) Identify diagnoses to be used in care management and active medical management in the furtherance of treatment Formulate a list of current and past medical conditions using clinical knowledge and judgment and the findings of your assessment Communicate findings in your assessment that will be used to inform member’s PCP of potential gaps in care Identify urgent and emergent situations and intervene appropriately Educate members on topics such as disease process, medication, and compliance