Care Coordination Services

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Care Coordination is a part of the Access and Assistance system offered through the Area Agency on Aging.   It is a process that includes the assessment, effective planning, arranging, coordinating and follow-up on services that most appropriately meet the identified needs as mutually defined by Area Agency on Aging access and assistance staff, an older person, and/or a family member or other caregiver.   The aging network uses local, state, and federal funds to provide this service to as many as possible.   Client referrals are accepted from any source.

Services Provided Through Care Coordination
  • Health Maintenance: The provision of services, medications, and/or equipment which will prevent, alleviate, and/or cure the onset of acute and/or chronic illness, increase awareness of special health needs and/or improve the emotional well-being of and an older individual.

  • Income Support:   A provision of aid in the form of money or goods.

  • Homemaker Services: A service provided by trained and supervised homemakers involving the performance of housekeeping and home management, meal preparation, or escort tasks and shopping assistance provided to older individuals who require assistance with these activities in their place of residence. The objective is to help the recipient sustain independent living in a safe and healthful home environment.

Care Coordination service is available to persons 60 years of age and older. Services will be targeted to those eligible persons who will be able to regain their independence by receiving short-term support services. Care plans are developed on an individual basis with input by the client and/or caregiver. It is the estimation of this agency that care plans will be no longer than three months and can be extended to six months if necessary. The program is to promote independence, not dependence.















Eligibility Requirements

Provision of services through the Care Coordination program may be given to those who:

  • Have recently been hospitalized or suffered a health care crisis (recently has been defined as within the last 30 days);

  • Have a mild to moderate impairment or a temporary severe impairment (official impairment level determined during in-home assessment by Care Coordinator);

  • Are in great economic or social need, with particular emphasis on low-income minority persons:

  • Have a limited or no formal/informal support system; and

  • Reside in a rural area.

For more information contact us at 325-223-5704 or toll free at 1-877-944-9666.