Role of the Care Manager

The coordination of services for a person eligible for OPWDD supports is done through a dedicated Care Manager. Care Managers work for several Care Coordination Organizations throughout New York State and are paid for by OPWDD.

The Care Manager supports the person and their family in facilitating what's called the Life Plan Meetings. The Care Manager ensures that all relevant information is gathered and reviewed to inform the development of and updates to the Life Plan during the Life Plan Meetings. 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 (family members, service providers, care manager, etc).  The Life Plan captures the person’s comprehensive needs and meaningful goals, 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, in a manner that is accessible to them and distributed to the parties involved in the implementation of the plan. A Staff Action Plan will then be developed by the appropriate habilitation provider and will describe, in detail, what the habilitation service provider will do to help the person reach their goals and valued outcomes. 

Valued Outcomes will be linked to measures like security, community, relationships, choices, and goals. For more information on personal outcome measures, see Council on Quality and Leadership (CQL) POMS Measures. 

Once a person has met with their Care Manager and developed their initial Life Plan, the Care Manager monitors the person's progress. The Care Manager will be a partner in ensuring the Life Plan accomplishes what it is intended to do: help the person achieve their meaningful life goals.

 Throughout the Life Planning and Service Delivery Process, Care Managers will want to know:

• 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?

When changes to the Life Plan are needed to help the person achieve their goals, the Care Manager works with the person to update the plan.