Role of the Care Manager

The coordination of an individual’s care is done through a dedicated Care Manager who oversees and coordinates access to all services. 

The Care Manager to support the person as he or she facilitates the Life Plan Meeting (to the extent the person prefers to do so) and to also ensure that all relevant and pertinent information is gathered from the care planning team, including habilitation providers, and reviewed to inform development  of and updates to the Life Plan at the Life Plan meeting. Such information may include but is not limited to:

• Medical/health status
• Plan of Nursing Services
• Behavioral Support Plans
• Medication updates/changes
• Habilitation needs
• Safeguard needs
• Staff Action Plans

Each Life Plan has the following sections:

1. Profile of the person
2. Personal outcomes
3. Health and safety supports (as stated in the Individual Plan of Protective Oversight (IPOP))
4. Home and Community Based Waiver and Medicaid-authorized services
5. Supports

The Life Plan development is a team effort driven by the person in collaboration with the entire care planning team to ensure that the Life Plan captures the individual’s comprehensive needs and meaningful goals/supports so that services and supports are tailored to help the person achieve what is most important to them. The Life Plan must be written in plain language and in a manner, that is accessible to the individual, and distributed to the individuals and parties involved in the implementation of the plan.  The Staff Action Plan is then developed by the appropriate habilitation provider and will describe, in detail, what habilitation staff will do to help the individual reach the habilitation goals/valued outcomes through the habilitation provider assigned goal(s) identified in the individual’s Life Plan.

Valued Outcomes within the Life Plan must link to one of the twenty-one (21) defined Council on Quality and Leadership (CQL) POMS Measures. 

There are some key questions care managers can ask to ensure the Life Planning and Service Delivery Process is helping the person achieve their meaningful life goals.

• Is the person involved in life experiences that they value through their supports?
• Is there improvement in the person's life according to them (health, social, etc.) as a result of the services and supports that are provided?