CHS – Case Management
Mission: Support Native American families with respectful quality care, with pride, communication and trust for a healthier community.
RN Chronic Disease Case Management
Public Health Nursing & Long Term Care program to assist community members manage their chronic illness & medication management.
Service Description: RN’s help with (up to one time per week):
• In home medication management through medication set up. RN will bring medications if filled through OCHC pharmacy.
• In home chronic disease monitoring of vitals.
• In home chronic disease education & treatment plan education & advocacy.
• Chronic disease management of medical appointments when unable to do for themselves.
• Referral to other community resources.
Eligibility:
• Member of a federally recognized Tribe or Alaska Native Group.
• Established patient of the Oneida Community Health Center.
• Reside within the boundaries of the Oneida Nation’s Reservation.
• Meets medical and / or physical need to receive services.
• Individuals living outside of service area may be eligible for some on site RN services
What to Expect:
• Referral intake through office staff before routed to RN.
• Review of referral and client contact within 72 hours by RN to set up an assessment at your home.
• No cost.
• Participants are generally provided services on a first come first serve basis.
• Waiting lists are a possibility depending on service demand and availability of staff.
Community Health Representatives (CHR)
CHR’s provide a Public Health and Long Term Care service to assist community members to manage their chronic illness through access to medical care including medications.
Service Description – CHR’s help with (up to two times per week):
• In home chronic disease monitoring such as blood pressure checks.
• Medication delivery for those unable to pick up their medication.
• In home assistance with ordering medications if unable to do it by themselves.
• Medical care advocacy & referral to other community resources.
• Limited transportation for those unable to get transportation.
Eligibility:
• Member of a federally recognized Tribe or Alaska Native Group.
• Established patient of the Oneida Community Health Center.
• Reside within the boundaries of the Oneida Nation’s Reservation.
• Meets medical and / or physical need to receive services.
• Individuals living outside of service area may be eligible for some CHR services depending on staffing and demand.
What to Expect:
• Referral intake through office staff before routed to RN for assessment.
• Review of referral and client contact within 72 hours by RN to set up an assessment at your home.
• No cost.
• Participants are generally provided services on a first come first serve basis.
• Waiting lists are a possibility depending on service demand and availability of staff.
Home Health Agency Services
Oneida Home Health Agency Services in collaboration with PRN Home & Therapy Agency.
• In home Skilled Nursing services authorized with doctor orders for home bound patients.
• In home Physical Therapy (PT) authorized with doctor orders for home bound patients.
• In home Occupational Therapy (OT) authorized with doctor orders for home bound patients .
• Referral to other community health services and resources.
Eligibility:
• Member of a federally recognized Tribe or Alaska Native Group.
• Reside within Brown & Outagamie Counties.
• Meets medical need & home bound status to receive services.
• OCHC referral from Purchased Referred Care (PRC) maybe needed.
What to Expect:
• Referral intake through office staff routed to PRN for Oneida or PRN assignments.
• Review of referral and client contact within 24-72 hours by staff to set up an assessment at your home.
• Costs covered through one or a combination of the following: Medicare, Medicaid, Insurance and PRC.
Medical Transportation
Service Description:
Case Management Program funds are used to provide Medical Transportation via Oneida Public Transit to access medical related services. These can include medical, dental, optical, behavioral health and pharmacy. We no longer have access to passes so you need to call Community Health Services to arrange a ride and we will pay Transit for the transportation services.
Eligibility:
• Member of a federally recognized Tribe or Alaska Native Group.
• Established patient of the Oneida Community Health Center and Behavioral Health.
• Reside within the boundaries of the Oneida Nation’s Reservation.
• Need for transportation to medical service.
What to Expect:
• Referral information given to office staff.
• CHN staff member will review eligibility criteria then contact transit to arrange ride.
• No cost
• Participant needs to meet eligibility criteria to have ride paid for.
• Participants must contact Community Health to arrange transportation at (920) 869-4840.
• Participants must follow Oneida Transit guidelines to receive transportation services.
• Oneida Transit can transport to off reservation medical services, IF it is due to a referral authorized by Purchased Referred Care.
