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Advocacy,
Support and Training for Individuals and Families with Intellectual and
Developmental Disabilities to ensure that people receiving services
from the service providers are provided with opportunities to:
- live in the most integrated setting
- have meaningful and productive community
participation
- experience personal health, safety, and growth
- develop meaningful relationships with others
- have a choice about their service providers
- support individuals with the opportunity to
self-direct their services and ensure that the changing needs of the
people served are met.
Monitoring the activities of the
Care Coordination Organizations and Health Home (CCO/HH) providers to
ensured that the six health home core services are implemented to meet the
person-centered needs of the individuals receiving services.
The
required Six Health Home Core
Services:
- Comprehensive Care Management
- Providing Care Management related information to
the person and/or their family.
- Monitoring, following-up and enforcing effective
and quality service delivery.
- Creating documents e.g. LOC, DDP2, Life Plan.
- Requesting Service e.g. SAR.
- Responding to Emergency needs.
- Conducting assessment and Life Plan Meeting.
- Information sharing between providers and CM
- Care
Coordination and Health Promotion
- Providing education and advice to person and their
family on engagement and decision-making to promote independent
living.
- Providing education on wellness promotion and
prevention programs.
- Coordinating and arranging for the provision of
current and additional needed services and ensuring treatment
adherence.
- All health-related matters
- Comprehensive
Transitional Care
- Notifying the person and their family of the
established networks with local practitioners, health facilities
including emergency rooms, hospitals, and residential/rehabilitation
settings.
- Managing transitions e.g. from Residence to
community or hospital or school, etc.
- Managing transitions from one CCO/HH to another
- Following up with hospitals/ER upon notification of
admission
- Facilitating discharge planning from an
ER/hospital/residential/rehab setting to ensure a safe transition that
ensures care needs are in place.
- Notifying/consulting with treating clinicians,
schedule follow up appointments, and assist with medication
reconciliation
- Person
and Family Support
- Educating the person and their family on support
and self-help resources to increase knowledge, engagement, self-management
and to improve adherence to prescribed treatment.
- Coordinating of information and services to support
the person and their family to maintain and promote quality of life.
- Referrals to Health-related programs, peer
supports, support groups, social services, and entitlement programs as
needed.
- Providing education and directives to person and
their family on the person’s rights and health care issues, as needed.
- Fair Hearing
- Referral
to Community and Social Supports
- Providing advice to person and their family of
available community-based resources
- Working with person and their family to identify if
additional community-based resources are required and assist the
person with this as needed
- Identifying the resources and linking the person with
community support as needed
- Collaborating/coordinating with community-based
providers to support effective utilization of services based on needs
- Medicaid recertification
- Non-Medicaid funding e.g. SSI, Gym, SNAPPS, CDPAP,
Access-A-Ride
- Use of
Health Information Technology (HIT) to Link Services
- Providing access to the person and/or person’s
family member(s) and/or advocates and/or IDT member(s) as requested
and approved by the person.
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