About Care Coordination
The Care Coordination programs helps older adults remain independent at home by providing short-term services and support while they make future plans for care. The goal of the program is to help individuals maintain independence and/or support caregiver needs.
Care Coordination Eligibility
The service is available to adults ages 60 years and older who:
- Need additional attention during recuperation stages after hospital discharge
- Have recently suffered a major illness or healthcare crisis
- Have recently been hospitalized
- Have insufficient family support
- Have a mild to moderately impairment or a temporary severe impairment in activities of daily living and instrumental activities of daily living
- Are frail, isolated, and in great economic or social need.
Care coordinators will complete an assessment to identify needs and develop an individual care plan. Arrangement for appropriate services and their follow up is managed by an assigned care coordinator. The program provides assistance for those older adults who are without the financial resources to pay the total cost of needed care. A care coordinator assesses a person’s needs, then links clients to in-home services on a temporary, short-term basis.
Care Coordination Services may include, but aren’t limited to:
- Homemaker Service
- Health Maintenance (Supplies and Equipment)
- Minor Residential Repair
- Emergency Response Monitoring Services
All services are short-term, temporary, and are provided at no charge.
Care Coordination referrals
The following people can refer individuals to the Care Coordination program.
- Physicians
- Hospital discharge planners
- Social workers
- Nurses
- Family members
- Friends
- Any concerned person
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.
Call for more information:
The Ark-Tex Area Agency on Aging (AAA) is designated by the Texas Health and Human Services Commission (HHSC) to provide services to help people age 60 and older, their family members, and caregivers to help them receive the information and assistance they need in locating and accessing community services. Services are targeted to those with greatest economic and social need. Particular attention is paid to people with low-incomes, older people who belong to minority groups, and older people residing in rural areas. In addition, family members and other caregivers may receive information and services on behalf of the older person for whom they are providing care.