Improving Health Outcomes of individuals with I/DD
Through Care Management, our goal is to improve health outcomes of individuals with intellectual and developmental disabilities through brough access, holistic care, and person-centered planning. Our job is to ensure individuals under our care are set up for success in efforts to reach their highest potential and abilities. We work hard to help you develop good health habits, maintain healthy life choices, reach your desired level of independence, become empowered, and be your best self.
Care Management services provide individuals with intellectual and developmental disabilities a single designated Care Manager. The Care Manager works with each individual, guardians, family members and members of the individuals’ multidisciplinary team on an integrated care approach. Once care management has been initiated, and a comprehensive assessment is completed, our Care Managers and Care Navigators will ensure each individual has the right multidisciplinary team in place to provide services and supports that enables the individual to reach beyond the goals set in the care plan or ISP. Our staff will either meet with you face to face, through Web based applications or by telephone/cell calls.
Core Components of Care Management and Expectations
Care Managers are equipped to manage holistic needs spanning physical health, behavioral health, I/DD, TBI, pharmacy, long-term services, and support (LTSS), pharmacy services, and services to address unmet health-related resource needs (or Social Determinants of Health, SDOH). Care Managers will:
Care Coordination
Get to know you and the support and services you have, the support and services you need and how you want care management to work for you.
Develop your care management comprehensive assessment and care plan/individual support plan.
Coordinate, refer, and monitor all services such as medical, pharmacy, behavioral health, I/DD and Waiver services, including un-met health related needs such as food, housing, transportation, community resource supports, employment, education, legal, child welfare, etc. Contact a representative for a full list of all unmet health related needs serviced.
Transitional support from one clinical setting to another. Offering guidance on the discharge, coordinating care needs with personal providers, reviewing the discharge plan with you and critical caregivers, assisting in medication distribution reconciliation and management, creating and educating members of your team on a 90-day transition plan designed to ensure your success after your transition, along with facilitating arrangements for transportation, in-home services, follow-up appointments and updates to your comprehensive assessment and care plan.
Follow up on referrals and work with providers in coordinating resources during any crisis event as well as help in scheduling and preparing you for appointments (e.g., reminders and arranging transportation).
Provide referral, information, and assistance in obtaining and maintaining community-based resources and social support services, including Long Term Services and Supports, I/DD and TBI services (including Innovations and TBI waiver services), and any State-funded services.
Comprehensive assistance securing health-related services, including assistance with completing and submitting initial and renewal applications and gathering and submitting required documentation for Nutrition Services, temporary assistance for needy families, childcare subsidy, low-income energy assistance
Convene and consult with your multidisciplinary care team.
Provide support in managing your chronic, high-risk, high-cost conditions.
Provide Care Coordination to you if you receive Innovations or TBI waiver services.
Provide referral, information, and assistance in connecting you to programs and resources that can assist in securing employment, supported employment, volunteer opportunities, vocational rehabilitation, and training; or other types of productive activity that support community integration, as appropriate.
Twenty-four-Hour Coverage
Support beneficiaries in a crisis (with planning for the right supports during and after a crisis).
Arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis. Share information such as care plans and psychiatric advance directives with providers.
Coordinate care for placement in the most appropriate setting during urgent and emergent events.
Monitor hospital admission, discharge and transfers and ensure you receive transitional support through these events.
Annual Physical Exam
Support you in arranging for an annual physical exam or well-child visit, based on the appropriate age-related frequency.
Continuous Monitoring
Monitor progress toward goals identified in the care plan or ISP through contacts with you and your support member(s), and routine care team reviews.
Support adherence to prescribed treatment regimens and wellness activities.
Medication Monitoring
Help with medication monitoring, including regular medication reconciliation to support you in ensuring you know the medications and treatments you’re prescribed and why and support of medication adherence, all in conjunction with your doctor and pharmacist.
System of Care for Children and Youth
Utilize strategies consistent with a System of Care philosophy including use of knowledge around child welfare, school, and juvenile justice systems.
Promote a family-driven, youth-guided service delivery and develop strategies built on social networks and natural or informal supports.
Develop, with families and youth, strategies that maximize the skills and competencies of family members to support youth and caregivers’ self- determination and enhance self-sufficiency.
Ensure services and supports are delivered in the community within which you live, using the least restrictive settings possible to preserve community and family connections and manage costs.
Develop and implement proactive and reactive crisis plans in conjunction with the care plan or ISP that anticipate crises and utilize family, team and community strengths to identify and describe who does what and when.
Individual and Family Supports
Provide education in self-management.
Provide education and guidance on self-advocacy to you, your family and other caregivers or supports.
Connect you and your caregivers to education and training to help you improve function, develop socialization and adaptive skills, and navigate the service system.
Provide information and connections to needed services and supports including but not limited to self-help services, peer support services, and respite services.
Provide information to you, your family, and support members about the your rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes.
Promote wellness and prevention programs.
Provide information on establishing advance directives, including health care and psychiatric advance directives as appropriate, and guardianship options/alternatives, as appropriate.
Connect you and your family to resources that support maintaining employment, community integration, and success in school, as appropriate.
Health Promotion
Provide education on chronic conditions.
Teach and support you with self-health management (eating healthier, exercise, etc.)
Provide education on common environmental risk factors including but not limited to the health effects of exposure to second and third hand tobacco smoke and e-cigarette aerosols and liquids and their effects on family and children.
Conduct medication reviews and regimen compliance.
Promote wellness and prevention programs.
Who is Eligible for our Care Management Services?
Individuals aged 3 and older and who are or will be enrolled in a Tailored Plan and have an intellectual or developmental disability (I/DD), including:
Adults with I/DD who are NOT on the Innovations or TBI waivers
Innovations Waiver participants receiving Waiver services from another provider(including dual eligible)
TBI Waiver participants receiving Waiver services from another provider (including dual eligible)
iWaiver option participants
We’re here to support you in determining your eligibility through North Carolina’s Tailored Plans, too.
