Care Coordination Agencies (CCA) assist participants in gaining access to needed waiver and other state plan services. In collaboration with participants and/or their families, Care Coordinators complete an assessment and reassessment of waiver participants using the ALW Assessment Tool, every six months, or more frequently, as indicated by a change in the condition of the participant. Care Coordinators assist participants in the direct development of an Individual Service Plan (ISP). Participants who are unable to direct the development of their own ISP may be assisted by a family member or another responsible party, such as a legal conservator.
Care Coordination is on-going for the duration of time the participant is enrolled in the waiver. To ensure the timely delivery of needed services, a Social Worker conducts monthly face-to-face meetings with the participants at the ALW facility. If a participant leaves the assisted living setting due to hospitalization, or rehabilitation, etc… The CCA will continue to advocate for the participant for up to thirty days for the purpose of coordinating the participant returning to the assisted living setting.