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Agency on Aging of South Central Connecticut
Care Management Practice
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The Agency's model of care management: Utilizes a holistic perspective. Is a partnership with the client and their supporters in fostering the client's independent living in the
community. Is a dynamic, interactive, process among all players in the clients' care plan and among those assisting the client in residing in the community. Utilizes an active, problem-solving approach. Renders care management and payment
of services as an agent of the Department of Social Services, and therefore adheres to all CHCPE program regulations. Recognizes that professional consultation/ collaboration is the cornerstone of practice. Therefore, utilizes the skills of
our in-house consultation and supervision and consults with those professionals rendering care to our clients.
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The Agency's Assessment: Is a comprehensive, "whole person," assessment considering the client's, health, functioning, cognition, emotional/mental health status, support
system, environment and financial situation. Utilizes professional interviewing skills. Evaluates client strengths and weaknesses Evaluates the "why" of the deficit areas so that care plans are formulated with a remedial
approach which fosters client's maximum level of independence. Utilizes the input of other professionals and supporters involved in the client situation. Gathers information from a variety of sources so that care pans will be formulated on
as complete information as possible.
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The Agency's Care Plans: Are based on reliable, comprehensive, data gathered in the assessment process. Are developed utilizing the professional skills and critical-thinking of the
care manager in consultation with other staff members as appropriate. Are developed to reflect the client's individual situation. Consider all seven domains and strengths and weaknesses identified in each domain. Are based on clients'
identified needs, client preferences, program guidelines, Are cost effective and will produce measurable client outcomes. Utilize the informal and formal support systems. Utilize all appropriate community resources, as well as CHCPE- funded
services. Utilizes state funding as the payor of last resort.
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The Agency's Ongoing Care Management: Follows CHCPE prescribed guidelines for monitoring and reassessment. Utilizes a pro-active model as opposed to a reactive model. Provides
ongoing consultation and education for clients and their supporters. Is a continual assessment process, problem solving with the client and their support system utilizing a preventative framework of intervention. Is a continual assessment
process that supports timely and appropriate adjustments to the plan of care such as addressing increasing frailty or increasingly independent client functioning. Is a dynamic model of practice, reflecting the capabilities or lack thereof,
of the client and client system. Therefore, fostering maximal independence when appropriate or utilizing more aggressive care management in cases of incapable, at risk clients. Monitors the effectiveness of services and takes appropriate
actions when services are not rendered as contracted.
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