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Case Management: A Valuable Service for Elders. Shelly Zylstra Northwest Regional Council 360-676-6749. Overview. What is it? Different types of Case Management Assessment Knowing the resources Referral and Assistance Checking Back. Case Management.

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Case management a valuable service for elders

Case Management:A Valuable Service for Elders

Shelly Zylstra

Northwest Regional Council



  • What is it?

  • Different types of Case Management

  • Assessment

  • Knowing the resources

  • Referral and Assistance

  • Checking Back

Case management
Case Management

  • Is usually considered to be an activity where evaluation and assessment, assistance and referral, and intensive oversight is provided for elders who:

    • Have multiple unmet needs

    • Have little or no functional family or other “informal” support

    • Are vulnerable, frail, or lack the skills to work through the systems to get their needs met

Types of case management
Types of Case Management

  • Short Term

  • Long Term

  • General CM through Title VI

  • General CM through Title III

  • TXIX or Medicaid CM

  • CM for individuals living in facilities

Short or long term
Short or Long Term

  • Difficulties in life make it difficult

  • Doesn’t mean it is forever

  • May need intensive support during periods of illness, grief, personal upheaval

  • Assist and then back off

  • If unable to stabilize, long term assistance may be necessary

General case management
General Case Management

  • Not means-tested

  • No “rules” but ask for State standards to give you guidance

    • Usually it is good to have some social work education and a working knowledge of how long term care services work in your location

  • Important to keep a file for each elder you are case managing with notes about what you have done, when, and what the outcomes are

Title vi or title iii
Title VI or Title III

  • Use Title VI money to fund

  • Seek Title III resources from the local area agency on aging or ask for their assistance to help your elder

  • Be heavily involved in the process to be sure that the assistance is culturally appropriate

Medicaid case management
Medicaid Case Management

  • Means-tested; physical disability required that affects 1 or 2 Activities of Daily Living (ADL’s)

    • Dressing - Eating - Ambulating

    • Toileting - Hygiene

  • Elder usually qualifies for a variety of services under the Medicaid Waiver system in the state.

  • Enter through State or AAA

  • May offer case management for elders who live in facilities as well

The file
The File

  • Usually begins with an intake sheet

  • A copy of the assessment document

  • Copies of financial information and copies of any forms which have been completed and submitted

  • Release of Information from the client

    • Include what will be released and to whom

  • Advance Directives/living will

  • Service Plan—what the elder needs, who will do it, when they will do it

  • Progress notes—activities undertaken, documentation of visits, telephone calls, and copies of any correspondence

Intake and assessment
Intake and Assessment

  • Intake—gathering personal information about the elder

  • Assessment—has to be face to face

  • Review of needs, strengths, and environment


  • There are a variety of assessment forms in use—many are available online



  • Start slowly and simply and then branch out if you get better at it


  • Elder’s abilities

  • Elder’s support network

  • Elder’s income, assets, services accessed already

  • Elder’s environment and living situations

  • A good assessment will screen for the programs that you know exist in your area to determine if the elder is eligible for any of them.

Knowing the resources
Knowing the Resources

  • You need to have an understanding of the services available in your region…not just tribal resources

    • Get a resource guide from the Area Agency on Aging in your region or check their website

    • Call 1-800-677-1116 Eldercare Locator

  • It is your responsibility to know!

What do you know about these

Volunteer Services


Auto Repair

Medication Management & Assistance

Energy Assistance

Food Assistance

Pet Food Assistance

Home Delivered Meals

Chore services


Medicaid Transportation

HCBS Medicaid Waiver Services

Skilled Nursing

Assisted Living

Adult Family Homes

Home Repair

Diabetic Shoes!

Medicare Part A, B, D

What Do You Know About These?

If you don t know
If You Don’t Know…

  • You cannot help Elders Access important services

  • Find out what is available in your area

  • Keep a file of each resource

    • Requirements

    • Necessary documentation

    • Application Materials



  • Most elders will need help filling out forms, finding important documents, and making certain everything is in order

  • Develop a checklist for each program

You need to lead
You need to Lead!

  • Get courage to attend meetings off of the reservation

  • Join Boards of Directors or Advisory Councils

  • Go to Senior Centers in town and talk to the leadership there

Once is not enough
Once is not Enough!

  • Once you have the elder signed up for services, check back to see how it is going

  • If services don’t work, figure out why and offer to do training for service providers if necessary

Case management links elders
Case Management Links Elders

  • To services

  • To supports

  • To activities

  • To assistance

  • To resources

  • To others who can help them be as healthy and able as they can be and continue to provide leadership to the community

Care management
Care Management

  • Puts the care elders in your hands

  • Provides a way to coordinate services and providers to maximize their well-being

  • Is a necessary “next step” for Title VI Directors to take to advocate for the frailest and oldest in the community