The Senior Care System provides case management and funds for services for people 65 or older who may be at risk of nursing home placement. Senior Care allows seniors to live with dignity and in the comfort of their own homes and at a lower cost than nursing facility care. Senior Care provides a comprehensive assessment of an individual's needs, a case manager to secure and coordinate services, and a pool of gapfilling funds to purchase services for individuals who meet program eligibility requirements. Services may include personal care, chore service, medications, medical supplies, adult day care, respite care, home delivered meals, transportation, and emergency response systems.
- Coordination of Services
The Senior Care system of coordinated services is provided through the local aging, health and social services agencies. These services consist of screening, assessment, case management, and Gapfilling services. Screening and assessment are performed in-kind by any of the local agencies. Case management is provided both in-kind and paid for with Senior Care funds.
When older persons are referred for help, they are screened to determine if they may be eligible for Senior Care and other services. Screens are performed in-kind by all participating agencies and include information about an individual’s age, income, assets and functional abilities. If the individual appears eligible for Senior Care, a referral is made for a full evaluation of need.
Assessments are interviews conducted face-to-face with an older person and his or her family members or significant others. The assessment is used to determine if the client meets the established eligibility criteria and to develop a plan of care. Initial assessments are performed in-kind, usually by the local health department’s Adult Evaluation and Review Service (AERS). The Statewide Evaluation and Planning Services (STEPS) instrument is the most widely used evaluation tool. Baltimore City, Baltimore County and Montgomery County use other assessment instruments that they developed at the local level.
Upon completion of the assessment, a plan of care is developed that outlines services that the client is currently receiving and those that are still needed. This plan of care and the assessment information is forwarded to a case manager, who meets with the client to determine the services that the client will receive. This service plan is based on the client’s wishes as well as the availability of services and funds. The case manager completes reassessments for eligibility and need every six months.
- Case Management
Each Senior Care client is assigned a case manager. Case management can be provided by any of the participating agencies. Case management may be paid for with Senior Care funds, and/or provided in-kind by any of the three agencies. The case manager is responsible for implementing the care plan. This entails seeking out and ordering services, assisting the client or the client’s family to apply for other services, client advocacy, and overseeing services that are provided.