- Assessing needs (including the physical, psychological, and social needs of the individual)
- Developing service plans (such as hospital discharge plans)
- Coordination and monitoring service delivery (including coordination and monitoring to ensure that services specified in the plan are being provided)
- Providing follow-up and reassessment (revision of the status of the older individual, or if necessary, a primary caregiver or family member of the older individual)
- In accordance with the wishes of the older individual, advocacy for needed services or resources
An individual who meets all of the following:
- Customer requires minimal assistance with one or more ADLs or IADLs
- Customer requires services from multiple health/social services provider
- Customer is unable to obtain, coordinate, and monitor the required service for selfwithout assistance.
- Customer does not have a designated person acting on their behalf that is able and willing to provide adequate coordination and monitoring of services.
- Customer agrees to receive CM service including an in-home comprehensive assessment
- Customer is not eligible for duplicative CM services through any other agency.