Coverage Help
AxisCare posts the shift to the caregiver app. When it is not filling on its own, open a case here so the chase is visible: who has been asked, what they said, and how long the shift has been uncovered.
🔴 Open Shifts — next 14 days
Live from AxisCare: every scheduled visit with no caregiver assigned. Fill them in AxisCare; open a case below for any that aren't filling on their own.
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Nurse Visits
GHEs land in their state-assigned months and medication visits happen weekly — when in the month or week is between you and the client. Call them, set a time that suits you both, log it here.
🩺 GHEs — general health evaluations
Green is done, amber is this month, red is a missed window. Anything red is a compliance problem, not a scheduling preference.
👩⚕️ Caseloads — RN oversight
Every client with nurse needs, grouped by their nurse. Open clients are waiting for a PRN nurse to claim them. Red means that caseload needs the RN's attention.
📋 GHE forms — digital MO 580-2985
The nurse completes, signs, and marks it Ready for Fusion. The Medicaid care coordinator uploads it into Fusion and flips it to Uploaded. Getting the GHE done in its month is the coordinator's chase; doing it is the nurse's.
🪪 Nurse licenses
Expiration tracking. Amber at 60 days out, red when expired.
💊 Weekly medication visits
One per calendar week per client. "Last seen" is the number that matters.
Visit history
Nurse Portal
My caseload
🟡 Open clients — claim one
Claim it, then call the client and set your day and time together. The office is not the go-between.
My GHE forms
Overview
Today's priorities
Stand-up
One row per person: closed, due, late. Click a row to open their book.
🗣 The huddle questions (from Samantha's playbook) ▼
Safety & coverage: Are all clients safe and fully covered today? If not, where is the risk? Where do we have open hours or coverage gaps today?
Staffing focus: Based on open hours and care needs, what is today's hiring focus? (type of caregiver, skills, schedule, location)
Critical issues: What urgent client or family concerns must be handled today? What start of care, schedule change, or admission is at risk? What compliance, EVV, billing, or documentation issue needs attention?
Blockers: What is the single biggest blocker that could slow today down?
Round-robin close, everyone answers: "My priority today is ______." It must connect to client safety, coverage, hiring, or retention.
Staffing focus: Based on open hours and care needs, what is today's hiring focus? (type of caregiver, skills, schedule, location)
Critical issues: What urgent client or family concerns must be handled today? What start of care, schedule change, or admission is at risk? What compliance, EVV, billing, or documentation issue needs attention?
Blockers: What is the single biggest blocker that could slow today down?
Round-robin close, everyone answers: "My priority today is ______." It must connect to client safety, coverage, hiring, or retention.
🌱 Grow the agency
Inquiry Pipeline (this month)
Full breakdown — overdue, due today, new leads, completed
⚠️ Overdue
Due today
🆕 New leads with no follow-up set
✓ Completed today
💚 Keep clients happy · quality of care high
💚 Clients needing love
A kept client is worth more than a new lead — this list is how they stay.
📜 Communication Log
permanent record — every handoff, staffing request and meeting stays here; nothing can be deleted or cleared
📋 How Start of Care Works — the three ways a Medicaid case arrives ▼
A1Brand-new referral — the family calls us first and has never had HCBS services. We explain the program (DSDS decides eligibility, not us), get permission, and submit the referral in FUSION. DSDS assesses, and if approved, offers us the case.
A2PCCP transfer — they already have services but want to switch to us. We get consent and enter the PCCP request in FUSION; DSDS coordinates the transfer and sends the authorization (a new assessment usually isn't needed).
BDSDS calls us — the state offers us a case directly with the care plan and authorized hours. We decide whether we can staff it and notify DSDS.
→From acceptance on, all three paths merge into the same start-of-care checklist, through to the 24–72 hour follow-up calls. The evening coordinator owns FUSION entry, authorizations and care-plan input; daytime owns the welcome call, caregiver match and scheduling.
Start of Care
Every accepted case, from referral to first completed shift. Open the lead to check steps off.
Communication
Messages between the coordinators and the Staffing Coordinator — every one tracked until it's done, kept forever below.
📨 Send a message
The conversation — both directions, permanent
Inbox
Messages sent to the coordinators (and to the Owners, if that's you). Done items stay on the record below.
Meetings
Request a meeting — when it's accepted, both sides get a Join Video button. Camera, mic and screen sharing run in the browser; nothing to install.
＋ Request a meeting
My Work
Older views:
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Needs Attention
Everything open right now, with a name on it. Nothing here disappears on its own.
What belongs here: anything one named person has to do by a time. Missed calls arrive on their own;
use Add something for the rest. If it just needs a chat, go and have the chat.
The count on the tab is what is overdue, not everything open, so a red number always means something is late.
Arriving on their own: missed calls, and new leads that nobody has answered yet. A lead closes itself the moment anyone contacts them, so this only ever lists people still waiting.
Coming next: unanswered texts, caregiver call-offs and orientation no-shows.
Arriving on their own: missed calls, and new leads that nobody has answered yet. A lead closes itself the moment anyone contacts them, so this only ever lists people still waiting.
Coming next: unanswered texts, caregiver call-offs and orientation no-shows.
Phone Calls
Every call in and out of the office line, newest first. Recordings play right here.
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Family Circles
The people around a client who should hear the same thing at the same time. Coordinators and family only.
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EVV Corrections
The correction log from the Staffing hub, with its own sign-in.
Training
The training platform, signed in separately. Courses, progress and certificates all live here.
Applicants
Everyone who has ever applied, kept for good. Somebody who was right but early is the cheapest hire you will ever make.
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🧭 How hiring runs now — read this once
Most of this happens without you. Your job is the judgement calls and the screenings only you can run.
- You make the offer on the Offer a Job tab. Paste their details from Augusta rather than retyping.
- Their start link sends itself. They get a text and email asking for references and the details the Family Care Safety Registry needs. This is the fastest way to get reference checks moving, which is the slowest part of hiring.
- They appear here on their own once they fill it in, with references already in place and a fingerprint check flagged if they have lived outside Missouri.
- Their references get asked automatically and answer five questions on their phone. The answers score themselves, exactly as if you had called.
- You run OIG, EDL and FCSR, because those are state systems only a person can use.
- Two positive references and three clear screenings turns them green and lights up the orientation invite.
What still needs you, and when:
- A negative reference or a flagged screening shows up in Needs Attention within four hours. Read it before that person goes any further.
- A reference who goes quiet gets one reminder after two days. After five we ask the applicant to help, since it is their job waiting. Only after nine does it become a phone call for you.
- Viventium Step 1 is their paperwork, not yours, but nobody gets an orientation until it is done. The Step 1 chip on their row tells you.
📬 What they actually get
every message and page a new hire and their references see. Open one to read it.
These are the live pages, not pictures of them, so what you see here is exactly what was sent this morning.
Clicking inside a preview does nothing on purpose. Use Open the real page to try one properly.
Where everyone stands
start link, references, screenings, Viventium. Red is waiting on you.
📋 How This Tab Works — Step by Step
▼
How candidates get here
1
Candidate completes their application in Viventium. This triggers an email to Gmail and automatically adds them to this tab.If a candidate doesn't appear, check that Viventium sent the notification and manually add them using "+ Add Candidate."
Your checklist for each candidate
2
Run OIG Exclusion Check — click the OIG button on their row. Must be clear before proceeding.You can also run a batch OIG check for all pending candidates at once using the Batch OIG button.
3
Order FCSR Background Check — done manually through FCSR. Log the date ordered and mark clear/failed when results arrive.
4
Send Reference Forms — click "Send Refs" to email the reference form link to each reference the candidate listed. Requires 2 positive references.Reference form URL: mo-care.com/reference-form — responses are auto-scored and appear in the candidate record.
5
Fingerprint — schedule if required. Log the date completed.
6
Once OIG ✅ + FCSR ✅ + 2 Refs ✅, the candidate's status automatically changes to Ready for Orientation. Notify the team to book them into an orientation session.
7
If any check fails, status moves to Needs Review. Document the reason and determine next steps with management.
Processing Stats
📊
Use the Stats filter button to see how long each candidate is taking — we aim to get applicants to orientation as fast as possible.
| Candidate | Ref 1 | Ref 2 | Ref 3 | Ref 4 | OIG Check | EDL Check | FCSR BG | Fingerprint BG | Status | Actions |
|---|
📋 How This Tab Works — Step by Step
▼
Scheduling a session
1
Click + Add Session to create an orientation. Set the date, start time (default 10am), capacity, location, and who is running it (facilitator + role).The session will automatically sync to Google Calendar and create a shift in AxisCare if those webhooks are configured in Settings.
2
To schedule repeating sessions, use the Repeat dropdown (weekly, biweekly, or monthly). The hub creates all sessions in one step and tags them as a series.
Booking candidates in
3
Once a candidate is Ready for Orientation in the Background & References tab, click 🔗 Copy Booking Link on a session and send it to them. They pick their preferred time from a self-serve page.Or click + Add Booking to manually add a candidate (useful for phone/text bookings).
4
Session capacity fills up automatically. A FULL badge appears when there are no open spots.
Day of orientation
5
After the session, switch to Past Sessions & Attendance and mark each attendee: ✅ Attended, 🚫 No-Show, 📅 Rescheduled, or ❌ Canceled.
6
For anyone who Attended, click the 🎓 Promote button to move them into the Active Compliance tab as a new caregiver.
7
For No-Shows, follow up and rebook them into the next available session using a new booking link.
⚙️ Orientation Settings — Schedule & Defaults
▼
Recurring Weekly Schedule
Generate Sessions
Session Defaults
June 2026
Su
Mo
Tu
We
Th
Fr
Sa
Click a highlighted day to view its sessions
All Upcoming Sessions
📋 How This Tab Works — Step by Step
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How caregivers get here
1
Caregivers appear here after completing orientation and being promoted from the Orientations tab. You can also add them manually with + Add Caregiver.
Training milestones to track
2
Agency Orientation + ALZ Training (6 hrs total) — must be completed before the caregiver can be scheduled with their first client.
3
First Client Contact — log the date the caregiver was first scheduled with a client. This starts the 30-day OJT clock.
4
OJT In-Home + Online (12 hrs total) — must be completed within 30 days of first client contact. The 30-Day Training Due filter highlights anyone approaching or past this deadline.
5
Annual 5-Hour Training — required every year starting year 2. Use the Annual Due filter to see who is coming up.
Flags to watch
⛔
The Client Contact Blocked filter shows caregivers who have not completed their orientation/ALZ training and should NOT yet be scheduled with clients.
| Caregiver | Hire Date | Agency Orientation + ALZ 6hr — cleared to schedule | First Client Contact | OJT In-Home + Online 6hr — all 12hr due within 30 days | Annual 5hr yr 2+ | Overall | Actions |
|---|
📋 How This Tab Works — Step by Step
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Ongoing compliance checks
1
This tab tracks all active caregivers for recurring compliance requirements. Three checks must stay current: OIG Exclusion, EDL, and FCSR Background Check.
2
Use the 🔍 Batch OIG Check button to run the OIG exclusion check on all caregivers at once. This should be done regularly (monthly at minimum).OIG only requires first and last name — no SSN or date of birth needed.
3
Use the Overdue and Due Soon filters to prioritize who needs attention. Red = overdue, yellow = coming up within 30 days.
Supervisory visits & performance reviews
4
Log Supervisory Visit dates and Performance Review dates in each caregiver's record. These are required for Medicaid compliance audits.
Import / Export
5
Use 📥 Export CSV to download your full caregiver list for reporting. Use ⬆ Import CSV to bulk-upload caregivers using the provided template.
| Caregiver | OIG 90 days | EDL 90 days | FCSR annual | Fingerprint BG | Supervisory Visit annual | Performance Review annual | Actions |
|---|
📋 How This Tab Works — Step by Step
▼
- Log every attendance event the moment it happens — a call-in (the hub computes the notice automatically; less than 4 hours = write-up required per Handbook 2U), a tardy, or a no-call/no-show (immediate termination review per 2U — Samantha is alerted and makes the final call).
- The hub counts events per caregiver and applies the corrective-action ladder from Handbook 2V the same way every time: Verbal Warning → Written Warning → Final Written Warning → Termination Review.
- When a write-up is due, the caregiver's card shows a red button — click it and the document is drafted for you with the facts, dates, history and policy language. Print it, review it with the caregiver in person, have them sign (a signature confirms receipt, not agreement), then Mark issued and file the signed copy in Viventium.
- Every write-up — warning or termination — is approved by Samantha or Zach (the owners) before it can be issued. Nobody else can approve discipline.
Attendance write-ups draft themselves from the cards below. Everything else lives on the
Write-Ups tab →
⚙️ Policy thresholds (editable — the ladder applies these consistently)
➕ Log an attendance event
No attendance events logged yet — the record starts with the first log.
🔎
Scan AxisCare clock-ins (last 7 days)
ℹ️ Caregivers aren't clocking in through AxisCare yet, so shifts show "no clock-in" even when they were there — treat results as leads to check, not facts. Once the team moves to AxisCare EVV, this scan becomes automatic tardiness detection.
Write-Ups
Every corrective action and what stage it is at. Samantha or Zach approve before anything is issued.
Recruit
Everything that brings applicants in: what we post, what each role pays and asks, and where it goes.
📣 Our own job postings
published to mo-care.com/careers, where Google for Jobs can find them.
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Interviews
Applicants book their own interview when they apply, against the hours set on Team → Calendar. Once somebody is a good fit, Make them an offer carries their details across.
🗓 Our interviews
booked by applicants themselves, against the hours on Team → Calendar.
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📅 Interviews booked through Augusta
read from Google Calendar. Ours are above; this stays until the Augusta contract ends.
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⚙ Connect a coordinator's calendar
On a computer at calendar.google.com (not the phone app): in the left sidebar under My calendars, hover your calendar → click the three dots → Settings and sharing → scroll a long way down to Integrate calendar → copy Secret address in iCal format, a long link ending in
Do not see a Secret address? It only exists on calendars you own, and a Google Workspace admin setting can hide it. If it is missing, tell Claude and we will connect the calendar a different way.
basic.ics. Only events with “interview” in the title or notes show up here, so personal appointments stay private. Do not see a Secret address? It only exists on calendars you own, and a Google Workspace admin setting can hide it. If it is missing, tell Claude and we will connect the calendar a different way.
Team Calendar
Interviews, orientations, care assessments and consultations all spend the same day. This is the one place that knows about all four.
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📅 Team calendar & availability
what each coordinator is free for, and everything already booked.
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On the calendar, next two weeks
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Interview length, notice and how far ahead
Nobody's hours can fall outside this, which is what stops a stray overnight block.
Changing these changes what the next applicant is offered. Nothing already booked moves.
Offer a Job
Make the offer while the interview is fresh. Saving it sends their start link, and everything after that happens on this tab.
✍️ New offer
the four sections below take about two minutes
👀 The welcome message they get at the Viventium step
💬 The text message
✉️ The email
This pair sends later, when you mark them entered in Viventium. The start link below is what goes out today. Both use the agency's GoHighLevel number, so it stays one thread.
Who they are
Their start link goes to both, so a missing one is a slower hire.
The job
The one thing nothing else captures, and the one that turns into "never started" when it is missing.
Prefilled from what they said when they applied.
Viventium has one plan today. Once role-specific plans exist there, they can be listed here.
What you learned in the interview
Caregiver attributes for AxisCare
Everything starts at Yes. Flip only the ones that do not apply.
Saving texts and emails them their start link straight away, which is what gets reference checks moving today.
Settings
Owners only — keys, integrations, staff roster, cadences and goals. Changes apply to every coordinator.
Supabase Connection
Use the same project as Staffing Hub — coordinators sign in with the same accounts, and this hub's tables live alongside caregivers in app_data.
AxisCare Integration
Find your site number in your AxisCare URL: https://XXXXX.axiscare.com
⚙️ These belong to the agency now
Everything below except the Supabase connection is shared with the whole team, on every device. Pasting a key here switches it on for Krystal too. You can also manage the same settings from the Admin page.
💬 Communications & Training Hub
One key switches on three things: the texts, emails and calls shown on a lead, the Sync from Training Hub button on the Training tab, and escalation alerts. It lives in the Training Platform project as hub_read_key and starts with cchub_.
Cadences
Transcript Retention
Visit transcripts can contain medical detail. Once a care plan is pushed to AxisCare, the structured plan is the record of truth — the raw transcript doesn't need to stick around.
🔗 Lead Intake (Website Form → Hub)
Every mo-care.com form posts to the token-gated lead-intake Edge Function (see assets/forms.js in the website repo) and lands in the Leads tab with source "Website" — verified end to end 2026-08-01. No Zapier involved. An earlier note here showed a raw database URL; that path was closed in the July security hardening and was never the real one.
POST https://zngsgedlsxinbygwmxwn.supabase.co/functions/v1/lead-intake?token=cclead_…🪄 Care Plan Generation Webhook (Hub → Zapier → AxisCare)
Fires when you click "Generate Care Plan." Zapier structures the transcript with AI and pushes the result back here and into AxisCare custom fields.
Staff & Notifications
Add each coordinator with the email they sign in with — that's how the hub knows who's who: it shapes their view, stamps their work, and powers the stand-up counts. Samantha's account always sees everything.
Staff & Access — read only
Who exists, what they belong to, and what they hold, read from the structural identity model rather than from any list of email addresses in the code. Nothing on this panel can be edited yet; managing access here comes after the authority cutover.
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Who gets reviewed
While somebody is learning, their work gets looked at before their oversight reduces. A rule here means the reviewer picks up a Review item each time that person finishes that kind of work. The employee’s own work is already done; the review is the reviewer’s.
Counts only this kind of work. Blank means no limit.
A backstop. Whichever comes first ends the rule.
🚨 After-Hours Escalation Protocol
Kept for reference (the On-Call tab was removed) — after-hours escalation steps live here if you ever want them surfaced again.
Admin Passcode
Keep this separate from staff login passwords.
📋 How This Tab Works — Step by Step ▼
How leads get here
1Leads come in by phone call, the website form, or a referral partner. Phone leads: add them manually with + Add Lead while you're on the call. Website/referral leads can flow in automatically once the Lead Intake webhook is connected in Settings.
Your checklist for each lead
2Log the call — capture their situation, who needs care, and urgency in the notes field.
3Schedule the in-home care assessment — click "Schedule Assessment" on their row. This creates a record in the Care Assessments tab and moves the lead to Assessment Scheduled.
4If they're not ready yet, set a follow-up due date — the Follow-up Due filter surfaces anyone you owe a callback.
!If a lead goes cold, mark them Lost with a reason — keeps your pipeline numbers honest without deleting the record.
5Once they sign on and are set up in AxisCare, mark Converted and paste their AxisCare client ID — this links the lead to their later Care Assessment and Check-in records.
How this works: this is your one list of everyone who needs a follow-up, sorted by when they're due. A lead with an AI-drafted recap shows a Review draft button — open it, approve it, send it, then mark it sent so nothing falls through the cracks. Use the branch cards to filter by follow-up type. "Log contact today" on a lead sets its next follow-up date automatically.
All drafts — pending, approved, and sent
📋 How This Tab Works — Step by Step ▼
1Add every organization that can send you clients — hospitals, rehabs, skilled nursing, assisted living, physician offices, senior centers — and the key people there (discharge planners, social workers).
2Log every touch: drop-bys, calls, emails, lunches, events. Takes 10 seconds and builds your relationship history.
3Always set a next activity when you log one — it lands on the 📅 Today tab so the relationship never goes quiet by accident.
!Orgs with no touch in 30+ days get a gone quiet flag. On the Leads intake, choosing source "Referral" and typing the organization's name links the lead to it — that's how the referral counts and the Reports leaderboard work.
Business Development
Referral Sources
🚗 Field weeks are kept, not found — this week's scoreboard
Target: 2 logged field outings each, every week. A visit that isn't logged here didn't happen.
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📍 Due for Outreach
longest-untouched first — keep these relationships warm
📋 How This Tab Works — Step by Step ▼
1Schedule the in-home visit from a lead (or click + Add Assessment directly for an existing client). Bring your phone with your transcription app (Otter, Fireflies, etc.) running during the visit.
2After the visit, open the record and paste the transcript link (or the raw transcript text if you don't have a shareable link) into the assessment.
3Click 🪄 Generate Care Plan. This sends the transcript to the Care Plan webhook (set up in Settings), which structures it into ADLs/IADLs, medical needs, goals, and a recommended service schedule, and drafts the AxisCare custom fields.
4Review the drafted plan in the Care Plans view — edit anything before it goes anywhere near AxisCare. You are always the final check, not the AI.
5Once it looks right, click 📤 Push to AxisCare — this writes the care plan into the client's AxisCare custom fields and creates/updates their profile.
!AxisCare custom fields aren't finalized yet — see the
AxisCare_Care_Assessment_Fields_Setup.md guide. Until those are created in AxisCare, pushes will save to Supabase but the AxisCare step will no-op.📋 How This Tab Works — Step by Step ▼
1Every active client gets a check-in call (or visit) on the cadence set in Settings (default: every 30 days). The Due This Week and Overdue filters tell you who to call. This board is Angiel's, new check-ins default to her; anyone can log one they happen to take.
2Log the check-in — how the client feels about their caregiver, any concerns, and a quick satisfaction rating.
!If a client raises a real concern, toggle Escalated and notify Samantha. Don't let a concern sit in a check-in note unaddressed.
3The next check-in due date is calculated automatically from today + your cadence setting — adjust it manually if a client needs closer attention.
📋 How This Tab Works — New Clients, Needs Scheduling ▼
1When a new client is added in AxisCare, they appear here automatically (via Zapier) needing their first caregiver. This is the last stage of intake: the lead converted, the assessment is done, and now someone has to actually be in their home.
2Each client card is a four-step checklist, in order: assign a caregiver in AxisCare, call and brief the caregiver, call the client to confirm, then enter the schedule in AxisCare. Call notes are required on both calls, they're what saves you when anyone asks "what was agreed."
3When all four steps and both notes are done, Mark Scheduling Complete. That also pushes a scheduling summary note onto the client's AxisCare profile automatically.
!A caregiver must have completed Agency Orientation + ALZ Training before their first client, check the Caregivers section before scheduling anyone new. And always check the Do-Not-Return log (Care Match Check-ins tab) before assigning.
🏠
New Clients — Needs Scheduling
Populated automatically when a new client is added in AxisCare via Zapier.
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📋 How This Tab Works — State Submissions ▼
1When a Medicaid In-Home Services lead is referred to the state, record it on the lead: open the lead, fill in the Medicaid IHS — State Submission block (DCN, county, submitted date, status). The lead then appears here automatically.
2The state's pace is slow and silent, so this board ages every submission: blue is recently submitted, amber at 10 days means follow up soon, red at 21 days means call DSDS now. A referral with no submitted date shows red until it's actually sent.
3After each follow-up call, update the status and set the next follow-up due date on the lead. When the state authorizes, set the status to Authorized, then run the normal conversion: AxisCare setup, and they land in New Clients for scheduling.
!This board belongs to Angiel (the Medicaid & VA coordinator) — chasing these submissions is part of the afternoon rhythm. CDS-only towns and pure CDS inquiries still don't belong here: Angiel does those intakes too, but on the CDS side, and they ride the CDS hub's own submission tracker.
🏛️
Referrals Pending State Authorization
Submitted to DSDS/DHSS and waiting. Follow up every 1–2 weeks; the day counter keeps score.
Recently resolved
📋 How This Tab Works — Care Match Check-in Calls ▼
💛Why this tab exists: a client will almost never call to complain about a caregiver, especially a fill-in. They just quietly get unhappy, and we find out when they leave. A 2-minute call after a shift catches it while it's fixable, and catches the wins too. This is not the monthly wellness rhythm next door in Client Check-ins: this tab tracks one specific client and caregiver match, two calls per match, then done. Every call ends in one of three outcomes:
⭐Favorite: the client loved them. Mark the caregiver as a preferred caregiver on the client's AxisCare profile so scheduling pairs them first from now on. A fill-in who clicks is a long-term match found for free.
💬Coaching: something small ("she likes the dishes hand-dried," "he wants the TV on for lunch"). Pass it to the caregiver kindly, it's a preference, not a write-up, and put it on their AxisCare record with one click below so it's never lost. Small coaching is what turns a fine match into a favorite.
🚫Exclusion: the client doesn't want them back. Logging it here puts it straight on the permanent Do-Not-Return log, then enter the exclusion in AxisCare so the schedule physically can't pair them again.
1After the first shift: any caregiver whose first visit with a client was in the last two weeks gets a call within a day or two. These are the calls that save clients.
2One good-fit follow-up about a month later: "still going well with ___?" If yes, that match is set: no more scheduled calls. Only a 🚩 concerns call brings a pair back on the list (re-check about a week later to make sure it got fixed). Long-standing match from before this tab existed? Click "known good match ✓" on its row instead of calling, it clears without a call.
☎️A script that works: "Hi, this is ___ from Caring Companions, just checking in. How did things go with [caregiver] this week? Anything they could do differently that would make it even better?" That last question is where the gold is.
💛
Who to call — every caregiver in a client's home, last 60 days
Live from AxisCare visits. Two calls per match: 🆕 first-shift call, then a good-fit follow-up a month later. After that a pair only comes back if a call raised concerns.
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📞 Log a check-in call
📒
Check-in history — permanent record
Every call, what the client said, and what we did about it. Feeds favorites, coaching notes, and the Do-Not-Return log.
No check-ins logged yet — the first one appears here.
🚫
Do-Not-Return Log — permanent record
Every client request that a caregiver not come back. Check this before assigning anyone. Entries can't be deleted — enter each one as a client-caregiver exclusion in AxisCare so the schedule physically can't pair them.
Nothing on the log.
📋 How This Tab Works — Monthly Care Plan Reviews ▼
💡Why this exists: clients decline faster than paperwork. A fill-in caregiver who walks in trusting a plan that says "walker" when the client now needs a Hoyer lift is a safety incident waiting to happen. So every active client's care plan gets confirmed every 30 days, no exceptions.
1Work the board top-down. Overdue and never-reviewed clients float to the top in red. A review can be an in-person visit, a phone call with the client or family, or a caregiver check, whichever fits the month, as long as someone who has actually seen the client confirms the plan.
2Ask the people on the shifts. "Ask caregivers" lists every caregiver who worked with that client in the last 60 days (live from AxisCare) and texts them the check question with one click. They see the decline first, weeks before anyone in the office does.
3Log what you learned and set the Level. Every client is Level 1 (Wellness), Level 2 (Personal Care), or Level 3 (Advanced Care). If anything changed, mobility, overnight expectations, meds, equipment, flag it. A changed answer isn't done until the plan in AxisCare is actually updated, the board holds a red "plan not updated yet" until you mark it.
!A Level change is a scheduling event, not just paperwork: a Level 3 client needs Level 3-capable caregivers on every shift, including fill-ins. When you bump a level, tell scheduling the same day.
🗂️
Every active client, every plan, every 30 days
Pulled live from AxisCare (every client with a completed visit in the last 60 days). Red means overdue or never reviewed; a flagged change stays red until the plan in AxisCare is actually updated.
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📋 How This Tab Works — Step by Step ▼
1Every caregiver needs a supervisory visit at least once a year for Medicaid compliance — a coordinator observes them in a client's home. Due date = last visit + 365 days.
2Use the Due Soon and Overdue filters to plan your visits — Due Soon shows anyone within the window set in Settings (default 60 days).
3During the visit, work through the checklist (punctuality, task completion against the care plan, client interaction, safety practices, EVV/documentation compliance) and rate overall performance.
4Log a proof link (signed form, upload to Drive) — this is what an auditor will ask for.
!Completing a visit here also updates the caregiver's "Last Supervisory Visit Date" in Staffing Hub's Active Compliance tab — same underlying caregiver record, two views.
📋 How This Tab Works — Step by Step ▼
1This tab is a read-only rollup — every other tab still owns its own data. It exists so you can see one client's whole story (lead → assessment → care plan → check-in history) without flipping between four tabs.
2Click View History on any client to see their full timeline, including the satisfaction trend across all their check-ins.
!Clients are matched by AxisCare Client ID when available, falling back to name. Keep that ID filled in on the Lead/Assessment/Check-in records so a client's history stays linked together correctly.
📋 How This Tab Works — the SOP Library ▼
1This is the one place that answers "how do we do things here." Every standard operating procedure either lives on this page or is linked from it, so a new hire or a covering coordinator never has to know which hub grew the answer.
2Documents are stored privately in the hub's database, not in the website code. Samantha and Zach can add one with + Add SOP: give it a title and paste the document text (Markdown headings, lists, and tables all render properly).
3Instructions for using each tab stay on that tab, in the "How This Tab Works" guide at the top. This library is for the procedures that span tabs or hubs.
!If a procedure changes, update it here the same day. An SOP that says the old way is worse than no SOP at all.
📚 Standard Operating Procedures
Stored privately in the hub. Everyone can read; Samantha and Zach can edit.
🚨 After-Hours Escalation Protocol
Owners edit this text in ⚙️ Settings → After-Hours Escalation Protocol.
📘 Staffing SOP documents
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These links are set in the Staffing hub's Scheduling tab (the ✎ next to each SOP) and shared to both hubs.
Also part of the library
📚 Coordinator Playbook — payors, the intake process, sales scripts, objection handling. The next pill over.
🗓️ Team Weekly Schedule — who's on, who's in the field, the coordinator books, and the field expectation in writing.
🛡️ LTC claim process — lives with the LTC Policy tools under Growth.
📋 "How This Tab Works" guides — at the top of every tab in every hub, instructions stay where the work happens.
The standing weekly rhythm for Krystal, Angiel, and Samantha. This page is the office copy — if the schedule changes, this is what changes.
🖨 Open full page / print ↗
📋 How This Tab Works — Step by Step ▼
1Caregivers fill these in at orientation at cc.mo-care.com/caregiver-profile.html. Photo, an optional short video, what they are best at, and what they would want a family to know.
2They arrive unapproved. Read it as a family would, fix any typos, then Approve & publish. Nothing is sent to anybody before that.
3Put their AxisCare ID in. AxisCare is where the schedule lives, so this is what links a profile to the person on a shift. Without it, this profile can be sent by hand but can never be sent automatically.
4Unpublish takes it out of circulation and keeps the record. Remove deletes the photo and video for good, which is what to use when somebody withdraws their permission or leaves.
!The link is unguessable but it is not secret: anybody a family forwards it to can open it. That is the trade for a page a family can look at without signing in.
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Sales funnel
Lead sources
Why we lose leads
Referral source leaderboard
🏡 HomeTogether Orders
Every order from the HomeTogether website lands here automatically, the shipping details, emergency contacts, care preferences, and a personal profile of the senior so a caregiver's very first virtual visit already feels like time with a friend. Click any order to open it.
🖥 Device tracker
📋 New-order runbook: ship a HomeTogether device
Golden rule: assign the Hub in the HomeSight Care Portal BEFORE it ships. An unassigned Hub will not set itself up when the family plugs it in.
- Order arrives (this tab + Stripe email). Note their shipping address and any add-ons.
- Care Portal → Accounts → Add: create the senior's account. First/last name, language English (en-US), Imperial units, their ZIP code (powers the weather on their TV), Central time zone.
- Open the account → Assign Wellness Hub: pick a Hub from the shelf by serial number (white sticker on the bottom). Icon turns from red to black when assigned.
- Write the serial on the order here in the hub, that serial is how we track the device for returns.
- Add-ons: channels are on by default (included). If they bought sensors / LTE / health readings, enable those modules on the account and pack the extra hardware.
- Invite the family: add their family contacts on the account, each gets a welcome email to register for the app and portal. Do this now so the app works the day the box arrives.
- Box and ship: Hub, remote (batteries in), HDMI cable, quick-start sheet. Same-day if ordered by early afternoon.
- They plug it in: Hub connects to Wi-Fi, registers with the cloud, updates itself, and their account comes alive. Offer the setup phone call from the order email.
- If they bought caregiver visits: coordinator calls within one business day to lock standing times, then schedule the recurring calls in the Care Portal.
When a customer cancels: send the return-label email (templates in 🎫 Support), and when the device comes back: Care Portal → set deployment status to not deployed, purge the unit with their tools, back on the shelf for the next customer.
Reorder devices when the shelf drops to ~3 spares: help.homesight.care → Submit Request → Order Request (min 2 Hubs; SIM choice T-Mobile or AT&T; ships to our office).
Feedback
Star check-ins from clients, families and caregivers, plus Caregiver of the Year nominations. Everything here also landed in your email the moment it was sent.
Consultation Bookings
Consultations booked on mo-care.com/book. The public calendar only offers times that are open here AND free on the connected Google Calendars below, so a family can never double-book a coordinator. Orientation sessions from the Staffing Hub block this calendar automatically too.
Scheduler settings
Times are Central. Changes apply to the public calendar the moment you save.
In Google Calendar: Settings → your calendar → "Integrate calendar" → copy the Secret address in iCal format and paste it here. Busy events on that calendar automatically block the public scheduler. Keep these links private, treat them like a password.
Caregivers Corner
The support community on mo-care.com/caregivers-corner. Nothing goes public until you approve it here. Replies you post from this tab appear with a "Caring Companions" badge.
Post a pinned prompt
A standing conversation-starter that sits at the top of the Corner (e.g. "Wednesday Wins: tell us one thing that went right this week"). Goes live instantly with the Caring Companions badge.
Waiting for review
Live on the site
Support calendar
HomeTogether Hire
Concierge matching. Caregivers apply and families request at tryhometogether.com/local; you interview + background-check caregivers, then personally introduce matches by phone or email. Nothing is ever public.
Caregiver applications
Family requests
Campaigns
Your designed email library, ready to send. Pick an audience, open an email to preview it exactly as it will arrive, choose recipients, and send a test to yourself first. Everything goes out through GoHighLevel and lands in each contact's timeline.
🎫 HomeTogether Support
Every "Submit a request" from the HomeTogether websites lands here. Open a ticket, click Reply to answer by email (the ticket number stays in the subject so the thread is easy to find), and set the status so nothing slips.
📦 Device return emails (cancellation flow)
When someone cancels HomeTogether: send #1 right away with the prepaid label. If the device hasn't arrived, #2 goes out around day 14 and #3 around day 25. The $300 fee only ever applies after all three, and it's waived the moment the device shows up.
1 · Right after cancellation
Subject: Your HomeTogether return label (prepaid, takes 5 minutes)
Hi {First},
Your cancellation is all set, no further charges. The only thing left is sending the Wellness Hub home to us, and we've made it easy:
1. Put the Wellness Hub, remote, and cables in any sturdy box
2. Print the attached prepaid label and stick it on (no postage needed)
3. Drop it off at any carrier location within 30 days
That's it. We'll email you a confirmation the moment it arrives and your account will be fully closed.
Thank you for letting us be part of your family's story, truly.
Warmly,
The HomeTogether team
2 · Day 14 nudge
Subject: Friendly reminder: your HomeTogether return label
Hi {First},
Just a gentle nudge, we haven't received the Wellness Hub yet. No worries at all, life gets busy!
Your prepaid label is attached again. Any sturdy box works, and any carrier location will take it, no postage needed.
If the label gives you any trouble, or the box already shipped, just reply to this email and we'll sort it out.
Warmly,
The HomeTogether team
3 · Day 25 final notice
Subject: Heads up: device return needed by {date} to avoid the $300 fee
Hi {First},
We want to make sure this doesn't cost you anything: the Wellness Hub needs to be dropped off by {date} (30 days after your cancellation). After that date, the $300 device replacement fee from our Terms of Service applies to the card on file.
The good news: dropping it off any time before then means no fee at all, and if it's already on its way, you can ignore this note entirely.
Your prepaid label is attached one more time. Questions or a hiccup with shipping? Just reply, we're happy to help.
Warmly,
The HomeTogether team
🛡 LTC Insurance Policy
Paste a client's long-term care policy and get an instant, clear breakdown, then set it up as a payor in AxisCare. See the family-facing LTC page ↗
📄 AI policy analyzer
Paste the policy or its benefits/summary pages. The AI pulls out the elimination period, daily & lifetime limits, benefit triggers, whether home care from an agency is covered, and what it all means for the client. Tip: on a PDF, select all (Ctrl/Cmd‑A), copy, and paste here.
⚙️ Set up LTC insurance as a payor in AxisCare
General flow, exact menu labels vary by AxisCare setup. Confirm as you go.
💳 First, confirm how the client wants to pay:
1. Assignment of benefits (direct billing) — the client signs an assignment and we bill the LTC carrier directly; they pay nothing out of pocket within policy limits. Set the LTC company as the payer.
2. Private pay + reimbursement — the client pays us at our rate and we give them paid invoices to submit to their carrier. Bill the client as Private Pay; use the LTC payer only to track the daily/lifetime limits.
1. Assignment of benefits (direct billing) — the client signs an assignment and we bill the LTC carrier directly; they pay nothing out of pocket within policy limits. Set the LTC company as the payer.
2. Private pay + reimbursement — the client pays us at our rate and we give them paid invoices to submit to their carrier. Bill the client as Private Pay; use the LTC payer only to track the daily/lifetime limits.
- Create the payer. Settings / Admin → Payers (or Payers & Bill Rates) → Add Payer. Name it clearly, e.g. “Genworth – LTC Insurance”, and set the type to Private Insurance / Long‑Term Care.
- Set the bill rate. Enter your agency rate (hourly or per‑visit) for this payer so invoices calculate correctly. If the carrier reimburses a fixed daily amount, still bill your true rate, the policy’s daily max is tracked in the authorization (next step).
- Add the payer to the client. Open the client → Payers / Authorizations → add the LTC payer. Set effective dates and enter the policy’s daily or monthly maximum as the authorization cap so AxisCare warns you before a visit exceeds coverage.
- Handle the elimination period. AxisCare won’t track the waiting period for you. Keep the client on Private Pay until the elimination period is satisfied (note the satisfied date), then switch the primary payer to the LTC payer from that date forward.
- Turn on direct billing / assignment. If the carrier pays the agency, add the carrier’s billing address to the payer and attach the required documents (signed plan of care, assignment of benefits, caregiver visit logs).
- Invoice & submit. Generate the payer invoice, then export the visit logs / EVV records the carrier requires and submit with the claim form. Most carriers want these monthly.
💡 Match the AxisCare authorization cap to the policy’s daily/monthly max, and re‑check the lifetime benefit pool every few months so care never outpaces coverage without a heads‑up to the family.
✅ Our claim process (quick reference)
- Free policy review. Get the policy or benefits letter, run it through the analyzer above.
- Verify benefits with the carrier. Call with the client to confirm elimination period, daily max, and requirements in writing.
- Assessment & plan of care. Arrange the professional assessment and plan of care the carrier requires.
- File the claim. Submit claim forms plus caregiver logs and invoices.
- Care begins, bill the carrier. Start care on schedule and bill directly, keeping documentation current.
📚 Coordinator Playbook
Everything you need to answer a family's questions with confidence — how every payor works, the intake process for each, and word-for-word scripts for selling blended care. When in doubt, verify eligibility before promising anything.
How families pay
Tap a payor to expand. Every family fits one — or a blend — of these five.
Private Pay Fastest start ▸
| Wellness Care | from $30/hr |
| Personal Care | from $32/hr |
| Advanced Care | from $34/hr |
| 24-Hour Care | $28–$32/hr |
| Live-In Care | $450/day* |
| HomeTogether virtual check-ins | from $75/mo |
*Live-In includes a $25/day caregiver meal fee. These are the only published rates — quote them exactly, never invent others.
Best for: families who need to start now with no eligibility wait, want flexibility, or don't qualify for a program. Lead with: our caregivers are screened, insured W-2 employees, backed by 24/7 support and backup coverage.
Medicaid — MO HealthNet HCBS $0 to family ▸
What it is: Missouri's Home & Community-Based Services pay for personal-care hours at home so seniors avoid a nursing facility. Two ways to receive it — the Agency Model (we employ and send the caregiver) or Consumer-Directed Services (CDS), where the client directs their own attendant (often a family member) and we handle the management/fiscal side.
Who qualifies: MO HealthNet (Medicaid) eligible · age 63+ or an adult with a disability · and meets nursing-facility level of care confirmed by the state's in-home assessment.
Covers: authorized personal-care / ADL hours (bathing, dressing, mobility, meals). Does not cover: room & board, or hours beyond the authorized units.
Watch out: care is capped at the authorized units — anything above that isn't reimbursed. Confirm remaining units before scheduling.
Veterans (VA) Underused — always ask ▸
Two very different paths — know which one you're on:
- Aid & Attendance — an increased monthly VA pension for wartime veterans (or surviving spouses) who need help with daily activities. The family uses that money to pay us privately. Start by connecting them to a Veterans Service Officer to apply.
- VA-authorized home care (Homemaker/Home Health Aide, Veteran-Directed Care, Community Care) — the VA authorizes and pays the agency directly. You must have the VA referral/authorization before care starts.
Always ask: "Did your loved one serve in the military?" It's the most-missed source of funding.
Medicare GUIDE (dementia respite) 75 hrs/yr ▸
What it is: Medicare's GUIDE program covers up to 75 hours/year of in-home respite for people with dementia — and we're an approved provider who bills Medicare directly.
Who qualifies: Original Medicare (Parts A & B) · documented dementia diagnosis · not living in a long-term facility · not on hospice or certain Medicare Advantage plans.
Process & limits: we check eligibility, coordinate approval with our GUIDE partner (typically 7–20 days), then care can begin. Respite hours only; they reset each program year and don't roll over. Full detail lives on the public Medicare GUIDE page.
Long-Term Care (LTC) Insurance Verify first ▸
What it is: a private policy that reimburses home care once the person qualifies. Benefits vary wildly by policy — never promise coverage before you read the policy.
Check these five things:
- Benefit trigger — usually needs help with 2+ ADLs or has cognitive impairment (confirmed by our assessment).
- Elimination period — days the family pays out of pocket before benefits start (often 30–90 days).
- Benefit amount — the daily or monthly maximum the policy pays.
- Agency requirement — many require a licensed agency and a written plan of care (we provide both).
- Reimbursement vs. direct bill — the family may pay us and get reimbursed, or we bill the insurer.
The intake process (every lead)
The hub tabs walk you through each step — this is the shape of it.
1 · Lead→
2 · Identify payor→
3 · Assessment→
4 · Verify / authorize→
5 · Start of Care→
6 · Ongoing
- Identify payor early. On the first call, find out how they plan to pay — and always screen for Medicaid, VA, and a dementia diagnosis (GUIDE) even if they lead with private pay. It's the difference between an affordable plan and a lost family.
- Verify before you promise. For Medicaid, confirm level-of-care + authorized units. For VA-paid and LTC, get the authorization or policy details in hand before the start date.
- Assessment sets the plan. The in-home Care Assessment drives the care plan and satisfies documentation for LTC and GUIDE.
- Start of Care is where private pay can begin same/next day — one of our biggest advantages. Say so.
Sales scripts
Say it warm, not salesy. You're relieving stress, not closing a deal.
Discovery questions — ask these before pitching anything:
- "Tell me what a hard day looks like right now for you and your mom/dad."
- "What's prompting the call today — was there a fall, a hospital stay, or just a slow build?"
- "Who's helping right now, and how are you holding up?"
- "Did your loved one ever serve in the military?" · "Are they on Medicaid, or do you think they might qualify?"
- "Has a doctor mentioned memory issues or a dementia diagnosis?" (opens the GUIDE benefit)
Selling blended care Your best tool
In-home hours + HomeTogether virtual check-ins = whole-day coverage for closer to half the cost. This wins the families who think they can't afford care.
The math that changes the conversation:
A family thinks they need 8 hours/day of hands-on care → 8 × $32 = ~$7,600/mo. Out of reach for most.
Blend it: 4 hours of morning Personal Care (bathing, meals, getting the day started) = ~$3,900/mo, plus HomeTogether at $75/mo for eyes-on wellness checks and video visits the rest of the day.
→ Whole-day peace of mind for roughly half the cost — and Mom is never truly alone.
A family thinks they need 8 hours/day of hands-on care → 8 × $32 = ~$7,600/mo. Out of reach for most.
Blend it: 4 hours of morning Personal Care (bathing, meals, getting the day started) = ~$3,900/mo, plus HomeTogether at $75/mo for eyes-on wellness checks and video visits the rest of the day.
→ Whole-day peace of mind for roughly half the cost — and Mom is never truly alone.
Blended-care pitch
"I hear you — around-the-clock hands-on care adds up fast, and most families can't sustain it. Here's how a lot of our families make it work and actually feel safer: we put a caregiver in the home for the hours that matter most — usually mornings, for bathing, meals, and getting the day going. Then HomeTogether keeps a gentle eye on things the rest of the day, right through the TV — video check-ins and wellness awareness, nothing complicated for your mom to use. You get coverage across the whole day for closer to half the cost of full in-home hours. Could I show you what that would look like around your mom's routine?"
HomeTogether is simple for the senior (works through the TV they already use), reduces isolation, and gives the family alerts and check-ins between caregiver visits. It's the natural add-on to every in-home plan.
Handling objections
Agree, reframe, offer a next step. Never argue.
"It's too expensive." ▸
Say"Totally fair — let's not start with full days. Most families begin with just the hours that relieve the most stress and add HomeTogether so there's coverage the rest of the day for $75 a month. Let's also make sure we've checked every source that could help pay — Medicaid, VA benefits, and, if there's a dementia diagnosis, Medicare respite. Can I run those with you? It's free to find out."
"Doesn't Medicare pay for this?" ▸
Say"Great question. Regular Medicare doesn't cover ongoing personal care at home — that catches a lot of families off guard. But there are real options: if there's a dementia diagnosis, Medicare's GUIDE program covers respite hours and we're an approved provider. And many families qualify for Medicaid or VA benefits. Let's see which fits — I'll help you check at no cost."
"We're not ready yet." ▸
Say"That's completely understandable, and there's no pressure. A lot of families start small — even a few hours a week, or just HomeTogether for peace of mind — so support is already in place before there's a crisis. Would it help if I did a free assessment now, so you have a plan ready the moment you need it?"
"I can take care of Mom myself." ▸
Say"You clearly love her, and no one will ever replace that. This is about protecting you too — burnout is real, and even a few respite hours or HomeTogether checking in keeps you from carrying it all alone. Think of us as backup for the moments you can't be there. Want to start with just a little and see how it feels?"
"Let me talk to the family / think about it." ▸
Say"Of course — this is a family decision. Let me make it easy: I'll email a simple summary with the plan and the costs so everyone's looking at the same thing. Could we put a quick call on the calendar for after you've talked, so I can answer their questions directly? What day works?"
Rates and program rules change — confirm current details with Samantha before quoting anything unusual. Payor eligibility must always be verified before care is promised.