Care Coordination


What is the Care Coordination program?

The Care Coordination program provides information and assistance along with a package of support services.  It is funded by the Health and Human Services Commission, administered by the Ark-Tex Council of Governments Area Agency on Aging, and is mandated by the Older Americans Act of 1965.  The Care Coordination program is designed to help elderly persons remain at home despite limited self-care capacities, through provision of short-term support services.  The Care Coordination program provides services in Bowie, Cass, Delta, Franklin, Hopkins, Lamar, Morris, Red River and Titus Counties.

Who does the Care Coordination program serve?
Persons age 60 or older who:

  • need additional attention during recuperation stages after hospital discharge; or
  • have recently suffered a major illness or health care crisis or have recently been hospitalized; or
  • have insufficient family support; or
  • are mild to moderately impairment or a temporary severe impairment in activities of daily living and instrumental activities of daily living; or
  • are frail, isolated, in great economic or social need
  • need and request the assistance of a Case Manager to obtain necessary services to resolve the identified problems

These services include, but are not limited to, the following:

  • Adult Day Care
  • Home Delivered Meals
  • Homemaker Service
  • Minor Residential Repair/Home Accessibility Modifications
  • Health Maintenance, such as Prescriptions, Supplies, Equipment, Vision, Pest Control and Emergency Response Monitoring Services

How long is a service provided?

  • three to six months
  • each case evaluated on a one on one basic
  • referral made to Texas Department of Aged and Disabilities Services (DADS) for permanent assistance

Who provide services?

Home Health Agencies

Home Delivered Meals Agencies

Medical Supply Companies

Contractors and Agencies that has agreed to be vendors

Who can refer individuals to the Care Coordination program?
Physicians, hospital discharge planners, social workers, nurses, family members, friends or any concerned person can refer individuals to the Care Coordination program.  The Care Coordination program works closely with the Health and Human Services Commission (HHSC), Hospice, Adult Protective Services (APS), other social service agencies and hospital facilities.