Case Management

This program assists frail clients with long-term, complex problems. Service includes:

• An in-depth, in-home assessment with a client, family members, and support network
• Development of a written care plan with input from client and family
• Implementation of the care plan through referrals, service arrangements, meetings with client and family, and case conferencing and coordination with appropriate services
• Ongoing monitoring and reassessment to be sure client's needs continue to be met and/or to implement additional services as client's needs change