Referral Information - Information for Case Managers and Service Providers
Referral Process
- Contact our Enrollment Coordinator at 1-866-419-1693 and give a brief description of the client
and his or her situation, or have the client/family call us.
- The Enrollment Coordinator will explain the program and schedule a home visit with the client.
- The Enrollment Coordinator will arrange to have an "options assessment" done in order to determine clinical eligibility.
Applicants must be determined "nursing facility eligible" before enrolling in Community LIFE.
- We will help the client apply for Medicaid, if appropriate.
- Once financial eligibility has been determined, Community LIFE will begin the assessment process by the
multidisciplinary team, and an individualized plan of care will be developed for the individual.
Who is an appropriate referral?
Community LIFE is designed to serve elders who live in the community
or who may wish to return to the community, if feasible. These elders may reside
in their own home or with their families. We seek to begin serving elders before they
are in need of 24-hour supervision so that the elder can benefit from early
intervention and our extensive preventive services in their own homes
for as long as feasible and enjoy the highest quality of life possible.
The following situations may indicate that a client may benefit from enrolling in Community LIFE:
- Fragmented medical care and supportive services
- Recent hospitalization due to illness or injury, resulting in decreased
functional ability
- History of multiple/frequent emergency room visits, hospital admissions,
or short term nursing home stays
- Frequent falls
- Having difficulties with medication management
- Socially isolated
- Caregiver burn-out
- Requires extensive time commitment by case manager to insure client
health & safety
- Utilizing maximum number of personal hours and services allowed by
the AAA
- Involved in an adult day care program, but frequently misses attendance
due to illness or medical frailty, or inability to utilize Access transportation
system
- Medically compromised with a diagnosis of mental illness.
- A degenerative, long term prognosis that the existing service system
has been unable to address (e.g. Multiple Sclerosis, ALS, CHF, etc.)
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