Provided to an older individual, at the direction of the older individual or a family member of the individual:
- by an individual who is trained or experienced in the case management skills that are required to deliver the services and coordination described in subparagraph; and
- to assess the needs, and to arrange, coordinate, and monitor an optimum package of services to meet the needs, of the older individual; and
Includes services and coordination such as—
- comprehensive assessment of the older individual (including the physical, psychological, and social needs of the individual);
- development and implementation of a service plan with the older individual to mobilize the formal and informal resources and services identified in the assessment to meet the needs of the older individual, including coordination of the resources and services—
- with any other plans that exist for various formal services, such as hospital discharge plans; and
- with the information and assistance services provided under the Older Americans Act;
- coordination and monitoring of formal and informal service delivery, including coordination and monitoring to ensure that services specified in the plan are being provided;
- periodic reassessment and revision of the status of the older individual with—
- the older individual; or
- if necessary, a primary caregiver or family member of the older individual; and
- in accordance with the wishes of the older individual, advocacy on behalf of the older individual for needed services or resources.
Additional considerations for time study:
This code should be used for all activities related to case management, including:
- Case management oversight and coordination of direct care services provided under Federal Aging Services, such as personal care, homemaker, chore, home delivered meals, adult day care/health, assisted transportation, congregate meals, nutrition counseling, transportation, and nutrition education
- Paperwork
- Clerical activities, such as making copies
- Time spent reviewing voicemails or emails
- Time spent consulting with a supervisor or supervising
- Travel including time spent arranging transportation
- Time spent entering information about the activity into a database or software program
- Calls, emails, or other communications to obtain clarification of an inquiry
Time study codes:
- 6a. Enrolled in Medicaid- Assisting an individual who is currently enrolled or applying for Medicaid.
- 6b. At risk of spenddown/institutionalization- Assisting an individual in accessing supports that may prevent or delay the individual from entering a nursing facility or other Medicaid-funded institution. It must be documented that the individual must meet the Spenddown Worksheet criteria.
- 6c. Non-Medicaid- Assisting an individual who is not currently enrolled in or applying to Medicaid AND is not at risk for spenddown and/or institutionalization.
