Care Management
I want to stay in my own home, but sometimes I need a little help!
What is care management?
We know that older adults and individuals with disabilities want to stay at home and as independent as possible for as long as possible. Care management (CM) can help prevent or delay the premature or inappropriate admission into a nursing home through services and support that promote continued independence in your own home or that of your caregiver.
These services seek to assist you with your activities of daily living (ADLs), like bathing, toileting, cooking, etc., through in-home services, such as personal care, respite care, home making, nutrition services, and nursing services. It also provides respite for family caregivers so they can continue to care for you.
I think this could help me or a loved one. What is the process?
After a preliminary qualification screening is completed over the phone, an in-home assessment is conducted by one of our registered nurse/social worker teams. The most often provided in-home services are personal care, homemaker, and respite care; however, services are determined based on conversations with your care team about your needs, informal supports available, eligibility for specific programs, and resources available to provide care.
Your care management team will:
- Meet with you and your key decision makers in your home to learn about your abilities, available support providers, and individuals needs related to your care.
- Work with you and your family to design a plan of care to meet your identified needs.
- Arrange for services from health and social agencies, personal resources, as well as family and friends.
- Remain in close contact with you, your family, and your service providers, adjusting services as needed.
- To qualify for Care Management, individuals must meet one of the following criteria:
- Have multiple and complex needs or problems
- Are unable to take care of his/her needs; and family and friends are unable to provide all of the care that is needed
- Is currently in an institution and no longer needs all the services available there, but needs help to return home
- Is currently living at home and considering a move to another living arrangement
What are the goals of Care Management?
- To define appropriate level of care to assist you in maintaining independence through both formal (paid) and informal (unpaid) supports.
- To provide support for frail older adults and individuals with disabilities to enable caregivers to continue their support of the individual’s independence.
- To avoid costly or premature or inappropriate institutionalization
What are the requirements for eligibility?
Care management serves persons age 60 years and older at 'high risk' of nursing home placement and those over age 18 with a disability. You may be considered 'high risk' if you have one of the following characteristics:
- Determined medically eligible for placement into a basic or skilled-care nursing or foster-care facility
- Functionally unable to provide self-care without assistance due to illness or declining health and without sufficient support for meeting needs
- Multiple, complex, and diverse needs
- Resides in a skilled or intermediate facility or other institution and no longer requires that level of care, but is unable to obtain needed community services to return home.
Eligibility is determined using a telephone screening tool and through a one-on-one in-home assessment. Eligibility is based on the level of assistance required to perform activities of daily living and your individual medical health needs. Some programs have no financial eligibility requirements but do ask for cost sharing; whereas others like the MI Choice Waiver, have very specific income/assets requirements and is provided without a request for cost sharing. We do ask individuals to consider sharing in the cost of these services, so that we can serve as many people as possible. Cost sharing is requested, but not required. Your care management team will go over this information with you.
For programs that do not have an income requirement, cost sharing is offered as a way to extend the services that can be provided beyond the resources available through Federal, state and local grant sources.
Service Functions
Care management provides the following functions to assist you in remaining at home:
- Assessment – a comprehensive in-person assessment of physical and socio/emotional functioning, medications, physical environment, informal support potential and financial status.
- Care Plan Development – a written plan of care which states specific interventions to be secured, the care manager and consumer establish which services will be secured and provided, as well as the frequency and duration of services.
- Service Arrangement – in-home health and social services for the consumer’s care are arranged and/or purchased by supports coordinators according to the frequency and duration established by the supports coordinators and consumer as approved in the care plan. Consumer-centered advocacy is conducted to ensure access to and appropriate use of community services.
- Follow-Up and Monitoring – on-going periodic contact with consumers and service providers is conducted to ensure that care plans are implemented as planned.
- Re-assessment – a standardized in-person reexamination of the consumer's physical, socio/emotional and environmental status, informal supports and financial status is conducted on a routine basis.
Services funded by traditional sources such as Medicare, Medicaid, private insurance, etc., are arranged when appropriate. Supports coordinators are experienced in accounting for these various funding options and can serve as advocates to make sure that you receive the services and benefits for which you are entitled. If you require services not covered by existing programs, your care management team will work with you and your family to determine available cost-effective care options. If finances allow private payment, you may be asked to either pay for services, if existing programs fail to provide adequate coverage, or share in the cost of providing care.
Is There A Cost To Participate In The Program?
The cost to provide the comprehensive assessment, care plan, and ongoing monitoring is primarily funded by the State of Michigan and local resources. Consumers are asked to share in the cost of the program according to a sliding fee scale; but no one is denied participation in the program based on inability to pay. All donations and cost sharing received are used to directly support the program. Care management will not be denied to a consumer on the basis of financial, social, or religious status.