Contractors shall perform the following activities under the EMHOT program: Conduct in-depth behavioral health assessments on an as needed basis for high-risk older adults, where they are in their community, or connect these individuals to the appropriate behavioral health care setting for further assessment Assess older adults’ needs for support in the community and refer to service providers to ensure older adults experiencing emotional challenges and behavioral health conditions have their underlying and/or contributory needs addressed Work directly with older adults experiencing emotional challenges and/or behavioral health conditions, in their homes, in a community setting, and/or using technology based on the individual’s preference Develop individualized, person-centered care plans Conduct in-home visits, counseling, and therapy Assist in connecting older adults to ongoing mental/behavioral health services as needed Provide care coordination, collaboration, and warm hand-offs between older adults and other network service providers as needed, including, but not limited to, aging services, housing, financial, and physical and behavioral health care supports Connect and refer older adults to community-based resources (including, but not limited to, Home Care, transportation, housing, MassHealth, etc.)
