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Care Management

The goal of this program is to help those most at risk remain independent. Our care management teams work to develop and implement a care plan to keep clients in their homes.

Who We Help

Our clients usually have difficulties taking care of several of their needs, or have multiple health problems requiring the use and coordination of numerous community services. Many are at risk of hospitalization or placement in a skilled nursing facility.

Care Management Programs

Multipurpose Senior Services Program (MSSP)

MSSP provides care management services for seniors age 65 and older eligible for Medi-Cal with no share of cost and at risk of premature institutionalization. The program’s goal is to foster and maintain independence and dignity for frail seniors who reside in their own homes.

Basic Eligibility Guidelines

To be eligible to receive MSSP services a client must meet the following criteria:

  • Must be 65 years of age or older
  • Medi-Cal eligible with no share of cost
  • Be at risk of placement in a skilled nursing facility or intermediate care facility
  • Require professional intervention to gain access to community services, maintain or utilize available services; or manage serious health conditions
  • Have a need for case management services and able/willing to participate in the program and follow a care plan
  • Have multiple health problems requiring the use and coordination of many community services

Senior Options, Advocacy and Referral (SOAR)

SOAR provides comprehensive care management services to frail and disabled adults age 60 and older, at risk of nursing home placement and ineligible for other care management and in-home-care service programs. The intent is to prevent premature or inappropriate institutionalization by providing a comprehensive assessment of client needs, service referral, care coordination, and client advocacy. There is a limited purchase of service component available within the program to provide for homecare assistance.

Basic Eligibility Guidelines

To be eligible to receive services a client must meet the following criteria:

  • Must be 60 years of age or older
  • At risk of institutionalization
  • Require professional intervention to access community services
  • Have a need for case management services and willing to participate in the program and follow care plan
  • Ineligible for other case management and in-home care service program

Linkages

The Linkages program is designed to be a gap filler, providing services to frail, at risk elderly and functionally impaired adults who are not receiving other case management services. The program’s intent is to prevent premature or inappropriate institutionalization by providing Care Management and comprehensive information and assistance services to client’s who reside in their own homes.

Basic Eligibility Guidelines

To be eligible to receive services a client must meet the following criteria:

  • Must be 18 years of age or older
  • At risk of institutionalization
  • Have a need for case management services and willing to participate in the program and follow a care plan
  • Must be considered “at risk” by meeting at least one of the following conditions:
    • Impairment in one of more areas of Activities of Daily Living
    • Impairment in two or more Instrumental Activities of Daily Living
    • Unable to manage his/her own affairs due to emotional and/or cognitive impairment
    • Impaired by virtue of a significant event or circumstance that has occurred within the past 12 months




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