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:

  1. 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


  1. 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


  1. 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


  1. 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


  1. 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


  1. 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.