SOUTHWESTERN CT AGENCY ON AGING INC

CARE MANAGEMENT: SWCAA IS CONTRACTED BY THE DEPARTMENT OF SOCIAL SERVICES (DSS) TO PROVIDE CARE MANAGEMENT SERVICES TO INDIVIDUALS ENROLLED IN THE CONNECTICUT HOME CARE PROGRAMS. THIS MEDICAID WAIVER SUPPORTS OLDER ADULTS AND YOUNGER PERSONS WITH DISABILITIES TO REMAIN IN THEIR HOME AND FOREGO PREMATURE INSTITUTIONAL PLACEMENT. SWCAA'S SOCIAL SERVICE PROFESSIONALS ARE RESPONSIBLE TO ASSESS THE APPLICANT'S FINANCIAL AND FUNCTIONAL ELIGIBILITY FOR THE PROGRAM. THE ASSESSMENT INFORMATION IS SUBMITTED TO THE DSS FOR APPROVAL. ONCE APPROVED, SWCAA DEVELOPS A CARE PLAN BY AUTHORIZING SERVICES FROM MEDICAID PROVIDERS THAT WILL SUPPORT THE INDEPENDENCE AND IMPROVE THE QUALITY OF LIFE FOR CLIENTS. CLIENTS ARE MONITORED AND CARE PLAN AUTHORIZATIONS ARE ADJUSTED BASED ON EMERGENT CHANGES OR NEEDS. MANDATORY HOME VISITS AND MONTHLY MONITORING ARE DOCUMENTED IN A CLIENT MANAGEMENT SYSTEM. SWCAA IS REIMBURSED BASED ON THE CENSUS AND COMPLETION OF REQUIRED ACTIVITIES.

TRANSITION: SWCAA IS DESIGNATED BY THE DEPARTMENT OF SOCIAL SERVICES TO ASSIST INDIVIDUALS WISHING TO TRANSITION OUT OF NURSING FACILITATES BACK TO THE COMMUNITY. THE SOCIAL SERVICE PROFESSIONALS WORK WITH NURSING HOME RESIDENTS TO OVERCOME BARRIERS THAT WOULD PREVENT THE INDIVIDUAL FROM RETURNING HOME. WORKING CLOSELY IN A TEAM THAT INCLUDES TRANSITION AND HOUSING COORDINATORS, THE SOCIAL SERVICE PROFESSIONALS DEVELOP A PLAN TO FIND APPROPRIATE HOUSING, IDENTIFY NECESSARY IN-HOME SUPPORTS AND INITIATE OTHER FORMAL AND IN-FORMAL SERVICES TO SUPPORT THE INDIVIDUAL. STAFF STAY WITH THE INDIVIDUAL FOR ONE YEAR POST TRANSITION TO SUPPORT THE CLIENT IN HIS OR HER NEW ENVIRONMENT.