Shelby County Community Medicine Program

You may qualify if you:

• Live in Shelby County and are at least 18.

• Have no insurance coverage for needed care, or your benefits are exhausted.

• Are not already receiving in-home care from another organization.

• Have a primary care provider (PCP) who can sign a plan of care at the start and every 90 days.

• Are independently mobile.

• All clients must be referred by their primary care provider to the SFD Community Navigator.

• The provider shares recent history/physical, demographics, medication list, recent notes, and the reason for referral.

• We will contact you within 72 hours of receiving a referral. If you accept, your admission visit happens within 10 days.

• We make at least three documented attempts to reach you; after that, your provider is notified and resumes follow-up.

• You can refuse services at any time.

To start a referral: Ask your provider to contact the SFD Community Navigator

Initial Visit (up to 2 hours)

A SCHD registered nurse and the SFD Community Navigator meet with you to review needs, medications, program guidelines/goals, and consent forms (including HIPAA). Together, we build a plan of care and schedule your next appointment. 

Plan of Care (90-day cycles)

After your assessment, SCHD/SFD send your plan of care to your PCP for signature. The plan remains in effect for up to 90 days and must be renewed (signed) every 90 days to continue services.

Ongoing Visits (30–60 minutes)

Visits may be weekly or every other week, based on need, and can be performed by SCHD RN/LPN/MA with the SFD Community Navigator. Every visit is documented.

Basic in-home support may include:

• Vital sign and weight checks

• Medication setup (1–2 week intervals)

• Pharmacy medication pick-up

• Mental health check-ins

• Education on a range of health topics

• Contacting your PCP about changes or concerns

• Documentation at each visit

Important: This program does not provide client transportation. 

• No fees for basic in-home care provided by SCHD and/or SFD.

• Additional services (e.g., vaccinations, blood draws, or extensive medical supplies) may have costs.

• Confidentiality: Your privacy is respected; all staff follow HIPAA.

• Safety & Infection Control: Proper hygiene, PPE, and safety protocols are required at every visit.

• Documentation & Communication: All visits are documented promptly; relevant updates are shared with your provider.

• Professional Conduct: Staff uphold ethics and treat all clients with respect.

• Emergency Protocols: Staff are trained to handle medical emergencies and contact the right authorities.

• Home infestation policy: If a home has an active infestation (e.g., bed bugs or cockroaches), in-home visits are paused until treatment is completed and written proof is provided

• Any adverse event, accident, or concern is documented.

• Policies are reviewed regularly; staff receive ongoing training as needed to maintain safe, effective care.

Clients may be discharged when:

• You choose to end services.

• You are not present for two scheduled visits.

• Services are no longer needed.

• You enter a long-term care facility.

• Upon death.

Send referral and the patient packet (recent H&P, demographics, medication list, latest notes, and reason for referral) to the Shelbyville Fire Department Community Navigator. We’ll handle contact, admission scheduling, and plan-of-care routing back to you for signature