Role of the Care Manager
Care Coordination Organization and Health Homes will assist individuals and/or their family/representatives with accessing services and benefits that support healthy, well–rounded and fulfilling lives. The coordination of an individual’s care is done through a dedicated Care Manager who oversees and coordinates access to all services.
It is the responsibility of 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
Life Plan Sections
Each Life Plan has the following sections:
- Profile of the person
- His or her personal outcomes
- Health and safety supports (as stated in the Individual Plan of Protective Oversight (IPOP))
- Home and Community Based Waiver and Medicaid-authorized services
Life Plan Goals
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 him/her. 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.
Key Questions to Ask
There are some key questions care managers can ask to ensure the Life Planning and Service Delivery Process is helping the person achieve his/her meaningful life goals.
- Is the person involved in life experiences that he/she values through his/her supports?
- Is there improvement in the person's life according to him/her (health, social, etc.) as a result of the services and supports that are provided?