CARE MANAGEMENT

We support individuals with a Mental Illness, Intellectual or Physical Disabilities to build meaningful lives.

Care Management is person-centered, collaborative, holistic, and clinically grounded. Through building relationships, we assist our clients to achieve tangible outcomes.

six outcome focus areas

benefits • housing • health • finance • Connection • vocational

  • Benefits: Obtain and maintain local, state, and federal benefits. Includes insurance; Medicaid; Medicare; housing vouchers; waivers; utility assistance; SNAP; SSI/SSDI; and more.

  • Housing: Locate and apply for appropriate housing. Maintain current housing and avoid eviction.

  • Health: Coordinate and enhance care for mental and physical health. Promote prevention and wellness.

  • Finance: Money management skills, future planning, PA ABLE, Trusts, Representative Payee Bill Pay.

  • Connection & Social Support: Build community engagement in areas of interest. Increase the strength of existing relationships and decrease isolation.

  • Vocational: Explore opportunities and strengthen skills for paid work, volunteerism, and educational attainment.

Development of a “Meaningful Life” PLAN:

We work with the person and their support system to identify needs, challenges and aspirations. Together we build a care plan to match current needs and future goals with the best supports. Through this process we create a comprehensive, sustainable plan designed to provide security and stability.

  • Clarifying the types of Special Needs Trusts and how they may support people living with a disability.

  • Highlighting tools that may be useful, such as ABLE accounts & True Link Cards.

  • Increasing knowledge on the topics of Power of Attorney & Guardianship.

SERVICE DELIVERY OVERVIEW

Care can be provided remotely, as well as in your home and community. 

Care Management is performed by human service professionals with Social Work or Psychology education.

Service is provided under a contract that outlines the desired scope for Care Management. Prescribed scope can include one of, or a combination of, the following:

ASSESSMENTS:

• Understand client’s history and present status.
• Comprehensive Personal Care Plan for identifying current needs.
• “Meaningful Life” Plan for future-focused recommendations.
• Annual Reviews of Care Plan for long term clients.

INTERVENTION OUTCOMES:

• Identify goals and solutions in the focus areas. 
• Benefits, Housing, Finance, Health, Social, and Vocation.
• Partnership with family, client, and interdisciplinary team to achieve goals. 
• Cover gaps, engage resources, and remove barriers to attain outcomes.

ONGOING SUPPORT:

• Can be engaged as needed throughout the life-course.
• Relationship driven.
• Person-centered and flexible:
- Medical Coordination and advocacy
- Monitoring of facility or care
- Financial management as Representative Payee
- General problem-solving and emotional support

care management is fee for service.

Consult our Fee Schedule and Contract Menu for more detailed information

CARE MANAGEMENT SERVICE BOUNDARIES

  • Cannot provide 24 hr service. We work during business hours only, but can help create safety plans for after-hours resources. 

  • Cannot preform health aide care.  We do not provide direct, hands on personal care for transferring, hygiene, etc. We can find solutions to personal care needs.

  • Cannot become a personal companion. Our clinical basis means respecting professional boundaries. Care Management is not intended to fulfill friendships or family roles. 

  • Cannot become a transportation service.  We can transport clients when it is conducive to clinical care needs and goals. However, we are not intended to do routine, regular transportation.

  • Cannot provide Nursing or Medical Care. We are not nurses. We cannot administer medications or provide medical nursing recommendations.

  • Cannot provide psychotherapy. We do approach client interactions with clinically grounded perspectives. But, our role is not to provide a course of treatment. We also do not maintain the same therapeutic distance. We are more intertwined with the client’s life system and are directive and collaborative.