We work closely with family members, advisors, schools and health care providers to identify concerns and create client-specific solution and plan of care. Our goal is to help our clients achieve the greatest independence and highest quality of care.
We will be your guide and advocate to achieve maximum functional capability for you and your loved -one.
With specialized case management we provide person-centered care to empower individuals of any age to live with the greatest possible independence and quality of life. Not only do we provide support on an on-going basis.
Here’s what we do:
- Current Service Contract (CSC) use of Care Management for 6 months to solve a target problem
- Review and update plans of care as needed and submit person-centered plans of care by-yearly
- Connect family to additional community -based resources
- Provide educational advocacy with written outlines
- Written narrative report
- Provide support with medical needs an equipment resource
- Assess eligibility for transitioning from school to life skills workshops.
- Counseling in person -centered approach through assessments and intervention planning.
We start by doing a face-to-face screening to discuss our Care Management Program for your family. We will do an intake assessment to then build rapport with the family while taking baseline data to assess prerequisite skills for plans. In this process, Care Manager and family member work together to create a Road Map identifying the present and future support needs and the steps the family will take to implement the Road Map for the care and security of your loved ones.
Information gathered from one-on-one discussions with you during the screening, will help the Care Manager determine individualized treatment goals for your loved ones. These goals will be reviewed with you prior to the start of the Care Management Service. Screening criteria may include, but are not limited to:
- Barriers to accessing care and services
- Advanced age
- Catastrophic or life-altering conditions
- Chronic, complex, or terminal conditions
- Concerns regarding self-management ability and adherence to health regimens
- Developmental disabilities
- History of mental illness, substance use, suicide risk, or crisis intervention
- Financial hardships
- Housing and transportation needs
- Lack of adequate social support including family caregiver support
- Low educational levels
- Low health literacy, reading literacy, or numeracy literacy levels
- Impaired functional status and/or cognitive deficits