The Care Management Program provides care management services for persons 60+ years of age who need assistance managing their care. Through the program, eligible participants receive the services of a Nurse and a Social Worker (Supports Coordinators) that complete a comprehensive assessment at the person’s home. After the completion of the assessment, the Supports Coordinators along with the participant and his/her family develop a care plan to meet the needs of the participant. As a part of the care plan, the Supports Coordinators will work to assist the participant and family to meet the individual’s needs by arranging private pay services when funding is available. The Supports Coordinators will monitor service delivery and the participant needs through monthly contact and in-home reassessments every three to six months depending on the participant’s needs.
Eligibility
- Age 60+ and at risk of nursing home admission.
Program Services
- Personal Care
- PERS (Personal Emergency Response System)
- Homemaking
- Medication Management
- Respite for caregivers
- Adult day services
- Home delivered meals
- Home Injury Control
Donation
Persons determined eligible for the program are informed about the cost of the assistance provided and requested to make an appropriate contribution according to their financial ability.
Becoming a Client
All persons referred to the program receive a telephone interview to determine whether they are appropriate to receive an in-home assessment. When it appears that the person might qualify for the program, a nurse and social worker visit the client’s home for an in-depth assessment of their needs. The assessment evaluates physical and mental health, functional status, current formal and informal support being provided, home environment, financial resources, and third party insurance coverage. If the individual is eligible after assessment, a service plan is developed with the older adult and/or family. Client care is monitored and plans are revised, as client needs change. Contact Us. Funded in part by the Michigan Department of Community Health.
