Care Coordination

Preventing or delaying institutional living is the primary goal of Care Coordination.   Older Persons who have had a recent health care crisis such as being in the hospital or experiencing an illness or injury, are linked with services that promote an independent and safe recovery.

You will be encouraged to participate in making decisions for your care by the Care Coordinator.   Arranging for the services you need, monitoring of the progress you make during your recovery, and being sure that the help you receive meets your needs are the main focuses of this program.

Care coordination is a process that includes assessing the needs of a client and effectively planning, arranging, coordinating and follow-up on services that most appropriately meet the identified needs of the client.

The services provided through Care Coordination are:

  • Health Maintenance:   The provision of services, medications, and/or equipment which will prevent, alleviate, and/or cure the onset of acute and /or chronic illness, increase awareness of special health needs and/or improve the emotional well-being of an older individual.
  • Residential Repairs:    Home repair services consist of repair or modification of a client-occupied dwelling that is essential for the health and safety.
  • Income Support:   Assistance with utility bills.
  • Emergency Response System (ERS) – Designed for those who have health needs, live alone, and are home bound.
  • Personal Assistance – Short term services for those who have had a recent hospital stay and are living alone without a support system to assist them.

Care coordination service is available to persons 60 years of age and older.   Services will be targeted to those eligible persons who have recently had a health care crisis and will be able to regain their independence by receiving short-term support services.   Care plans are developed on an individual basis with input by the client and/or caregiver.

Provision of services through the Care Coordination program will be given to those who:

  • Have recently been hospitalized or suffered a health care crisis (recently has been defined as within the last 30 days);
  • Have a mild to moderate impairment or a temporary severe impairment (official impairment level determined during in-home assessment by Care Coordinator);
  • Are in great economic or social need, with particular emphasis on low-income minority persons: 

         — Have a limited or no formal/informal support system;
         — Reside in a rural area.