Clinical Assessment and Eligibility (CAE)/Comprehensive Screening and Service Model (CSSM)

Clinical eligibility determinations for designated MassHealth screenings

The CAE/CSSM Unit consists of Registered Nurses who conduct clinical eligibility determinations for designated MassHealth screenings, including Adult Day Health, short and long-term Nursing Facility eligibility determinations of those in Nursing Facilities, as well as Nursing Facility eligibility determinations for MassHealth members residing in the community seeking Nursing Facility admission.  Administrative Support staff members obtain and process the required paperwork and documentation related to MassHealth screenings for Adult Day Health, Frail Elder Waiver, etc.

Transition Coordination

A Transition Coordinator works with the CAE/CSSM Registered Nurses as an integral part of the Interdisciplinary Discharge Planning Team to facilitate the transition of Nursing Facility residents in our service area expressing the desire to return to the community, as well as working with staff at Nursing Facilities outside our area when there are residents expressing the desire to return to the community in our service area.  Services include comprehensive person-centered planning and identification of barriers to discharge, housing assistance, MassHealth Waiver referrals, and community resource coordination.

Meet the Team

Joseph Ouko, RN – CSSM Clinical Manager

Gabriel Ortiz – CAE Supervisor

Luis Taforo – CAE Team Member

Chrystal Wesley – CAE Team Member

Zulma Ortiz (Not Pictured Here) – CAE Team Member