Case Management

As individuals grow older, their needs and lifestyles change. Environmental, social and medical services may need to be reassessed. Case Management can help identify resources before a crisis occurs and can help an individual locate the most appropriate resources and services to best meet their needs.

Services

Case Management services assist elderly and disabled adults and their caregivers to decide which community services they need in order to remain living in their home.

Case Management also helps identify providers, set up services and offer changes when needed. 

This service provides an assessment of the individual's environment, social, financial and medical needs. Adult Services and Aging Specialists may develop a care plan, coordinate needed services, act as the person's advocate with various agencies and assist with caregiver issues. 

Eligibility

Case Management services are provided as an integral part of other Adult Services and Aging programs. These include:

Adult Services and Aging Specialists' Role

The Division of Adult Services and Aging provides an array of services to assist eligible elderly and disabled adults in preventing or delaying premature or inappropriate institutionalization. The Adult Services and Aging Specialist will discuss different eligibility requirements and procedures for the programs available. In addition, there are many other agencies and organizations that have programs and services that can be accessed. 

Adult Services and Aging Specialists respond when an inquiry or a request for service is made by the individual or someone on the behalf of the person. These steps include assessment, care planning, monitoring and reviewing. 

Assessment

The assessment process begins when a referral or request is made for services. The Adult Services and Aging Specialist will begin to gather information with the present problem, the person's condition and what the initial request for service is.

Other information gathered during the face to face assessment may include:

  • presenting problem or initial request;
  • the person's present condition and need for services;
  • type of help already provided or tried by family, friends or neighbors;
  • appropriateness of the environment;
  • eligibility requirements (income, age, level of care, etc.) of programs; and
  • individual's strengths, goals and preferences.
Care Planning

Care planning is the process of developing an agreement between the individual and Adult Services and Aging Specialist regarding problems identified, outcomes to be achieved and services to be pursued in support of goal achievement.

Care planning is:

  • based on a comprehensive functional assessment;
  • involves the individual and informal caregivers in the process;
  • is problem oriented and goal directed;
  • plans for a specific period of time;
  • involves planning both formal and informal services;
  • is conscious of costs and
  • results in a written care plan.

Monitoring and Reviewing

Monitoring of a care plan is an ongoing process achieved by regular contact with the individual, caregivers and service providers. It is a process by which the Adult Services and Aging Specialist and individual reassess the current service plan to determine if it continues to be the best plan possible within the limit of available resources.

Most of the services provided by the Division of Adult Services and Aging require a formal review of the care plan be done at least every 6 months, or as needed.