Wayne County, PA - Aging Agency Services

Index of Care Management Services

      Homebound Meal Services
      Personal Care Services
      Respite Care Services
      Attendant Care Services
      Alternate Community Care Services
      Family Caregiver Support Program
      Protective Services
      Ombudsman Program
      Information and Referral Program
      Access Services
      Long Term Care Program
      Pre-Admission Assessment Process
      Policies

Care Management Department Social Services

Care Management is a comprehensive social services program designed to serve elderly persons in their own homes; to respect the older adult's right to self determination; to foster independence; and to enhance the quality of life for these most frail members of our community.

"Care Management" as a process is the evaluation of the unique conditions, concerns, and needs of frail older adults. That same process includes planning and securing social services to meet those varied and individual needs.

Senior citizens who require Care Management services often have multiple, complex problems. Typically, these clients are "house or home-bound", age 60 or above, who may live alone or with family members. These older adults are striving to maintain their independence for as long as possible in the least restrictive and most familiar environment - their own homes.

In an effort to help older adults preserve and maintain their independence, the Agency assigns a Care Manager (a trained professional social worker) to work personally with each client in his or her own home. These specially trained staff members act as advocates, consultants, and service brokers for their clients. The Care Manager assesses the specific needs of the client, arranges for necessary services, and ensures that services are coordinated appropriately and efficiently. This same Care Manager will continue to work with the client, on an ongoing basis, for as long as services are needed.

Services may be of long or short term duration, depending upon the client's individual needs. For example, an older adult who is about to be discharged from the hospital may require home delivered meals for a brief time during recuperation. However, a person suffering from the debilitating effects of a stroke may require help with bathing or other personal care needs on a lengthy, ongoing basis, for an indefinite period of time. In all cases, the Care Manager continually monitors and evaluates the client's condition and circumstances, and makes needed adjustments to the client's care plan.

Care Management Department staff is always available for questions and inquiries about situations and services. One easy phone call is your direct line to "caring" help.

Requesting Homebound Services

Anyone may request homebound services for themselves or another person. Requests are received and welcomed from concerned people such as family members, friends, neighbors, health care professionals, clergy...or anyone who recognizes the need for assistance and services.

A simple phone call to the Aging Office, 253-4262, will begin the referral process for you.

Homebound Meal Services - Home delivered meals may be available to older adults who are temporarily or permanently confined to their homes. To be eligible for this service the homebound older adult must be unable to prepare a meal for him/herself and have no one else in the home who can do so. An Agency Care Manager will assess the needs of the older adult and will determine whether he/she is
eligible for homebound meal services. Once approved for services, the Care Manager will arrange for 5 nutritious meals to be delivered to the client's home each week. Meals may be delivered hot or frozen, once a week or 5 times per week, depending on where the client lives within the county.

For additional information, please contact the Care Management Intake Worker at 570-253-4262.

Personal Care Services - Personal Care services are authorized for older adults whose primary need for "hands on" care has been established and is reflected in a Care Plan which has been developed by a Care Manager. Personal Care services may be provided in the home and can include bathing and hairwashing, dressing/undressing, feeding, toileting, grooming, meal preparation, shopping,
laundry and light housekeeping. (PLEASE NOTE: light housekeeping may only be provided when accompanied by personal care or respite care services.)

All of the services listed above are provided by Personal Care Assistants who are an integral and visible part of the Agency's service team. These experienced, certified Aides work at the direction of the Care Management staff and under a program supervised by the Agency's Community Health Nurse. Basic in-home personal care assistance may be provided under a number of Agency programs. More intensive in-home services are provided under the Alternative Community Care Program and these services are limited by specific guidelines.

For more information, please contact a Care Management Intake Worker at 570-253-4262.

Respite Care Services - Respite services may be available on an intermittent basis to caregivers of older adults. The goal of this service is to help relieve the stresses of constant caregiving while keeping a loved one in the comfortable, familiar surroundings of home and community for as long as possible. After a thorough, coordinated assessment by an Agency Care Manager and Community Health Nurse, a certified Personal Care Assistant may be assigned to a family for "respite" care. This Personal Care Assistant (P.C.A.) works at the direction of the Care Management Department and under a program supervised by the Agency's Community Health Nurse. The P.C.A. will remain in the home, assisting with the needs of the older adult while the caregiver takes a needed break: possibilities include shopping, doctor or dental appointments, or even something as simple as a walk, a nap or just "quiet time" alone.

For additional information, please contact a Care Management Intake Worker at 570-253-4262.

Attendant Care Services - Attendant Care includes a wide range of services or activities which are provided to functionally impaired older adults in an effort to enhance the highest level of independence possible for each individual served. Essentially, Attendant Care is personal care which is flexibly adapted to the client's individual needs and capabilities. Attendant Care is provided by licensed Personal Care Assistants, and although the program focuses on the personal care needs of the client, other in-home services may also be provided. A Care Manager will assess the client's needs and will prioritize services based on waiting list status. The Personal Care Assistant works at the direction of the Care Management Department and under the supervision of the Agency's Community Health Nurse.

For more information, please contact a Care Management Intake Worker at 570-253-4262.

Alternate Community Care Services - Intensive in-home services are available to a limited number of persons slated for nursing facility
care. Alternative Community Care Services, also known as Options II, provides community based care to an individual and his or her family at home in order to "divert" from, or delay nursing facility placement. This service is dependent on many factors such as the existence of strong family support and the availability of appropriate community resources. These supports and services must be readily available to ensure the adequate care and safety of the person being diverted from 24-hour nursing facility care. Some services provided through Options II may include expanded personal care services; respite for caregivers; adult day care; and provision of durable medical equipment or supplies which are not otherwise covered by medical insurance.

Available slots for this program are limited. Further information about these and other placement options can be obtained by calling the Long Term Care Services Supervisor at the Aging Office, 570-253-4262.

Family Caregiver Support Program - The Family Caregiver Support Program is designed to assist families who are caring for elderly
relatives in the same home. The purpose of this program is to reinforce - not replace - the care already being provided to an impaired older relative, and to reduce the stress associated with caregiving. This program is unique because it allows the caregiver to choose the service which the family feels is most needed to help care for the older relative at home, with only minimal involvement by the Agency.

Under this program, family caregivers may be eligible to receive financial assistance to help purchase services for the older relative (such as respite care or adult day care), or to purchase caregiving supplies (such as disposable briefs or equipment). In addition, caregivers may also be eligible to receive a one-time grant to help pay for home modifications or assistive devices to ease the task of caregiving and increase the functional independence of the older adult. Education, training, and benefits counselling are also provided under this program.

Financial assistance is available on a cost-sharing basis to help families with out-of-pocket expenses. Amounts of reimbursement are determined by actual expenses, household income, and availability of Agency funding.

Slots for this program are limited. For more information please call the FCSP Care Manager at 570-253-4262.

Protective Services - Protective Services are activities mandated by law under the Older Adults Protective Services Act which are designed to protect older persons who are at risk of abuse, neglect, exploitation, or abandonment. To be eligible for Protective Services a person must be over the age of 60, and lack the capacity to protect him/herself, and be at serious and imminent risk of danger to person or property. It is not the purpose of this Act to place restrictions upon the personal liberty of older adults, but to assure the availability of services for incapacitated older persons who may need them.

If mistreatment of an older adult is suspected, a report may be made 24 hours a day, 365 days a year, by calling the Agency's toll free "Elder Abuse Hotline" at 1-800-648-9620 or by visiting the Aging Office during normal business hours.

Ombudsman Program - What Is An Ombudsman? The word "Ombudsman" is a Swedish word meaning "citizen representative". The Ombudsman is actively involved in assuring that consumers of long term care receive the level of care and quality of life that they deserve. The Ombudsman is concerned with the individuals' health, safety, welfare and rights. A trained Ombudsman is available at the Aging Office to serve as a mediator and to investigate and resolve complaints which are made by or on behalf of persons over the age of 60 who are receiving long-term care services. The Ombudsman provides a mechanism for people to voice their concerns, to have their complaints addressed, and to work with all parties in an effort to solve a problem.

The staff Ombudsman will assist residents of Nursing and Personal Care Homes (or their relatives and friends), or aid individuals who are receiving long-term care services in their own homes and community. Typical complaints which are handled by the Ombudsman include: concerns about the quality of care or treatment of a resident of a long-term care facility; problems with billing and charges (eg. Medicare and Medicaid); complaints regarding transfers, discharges, or change in services; or appeal procedures.

You may contact the Agency Ombudsman by calling 570-253-4262.

Information and Referral Program - Access Services - During normal business hours, Monday through Friday, 8:00 AM to 4:00 PM, a Care
Management Intake Worker is available to provide information regarding services which are available through the Area Agency on Aging and/or to make referrals to other community agencies or resources, as appropriate.

Additional information may be provided to the public by the Agency's APPRISE Health Insurance Counsellor, clerical assistants and volunteer Senior Advocate. All of these people are adept with problem solving issues. They are also available to answer questions and to assist in the completion of applications such as PACE, Tax/ Rent Rebate, Medicare and Medigap insurance, etc.

Please call the Aging Office at 570-253-4262 and you will be directed to the Information and Referral staff member who can best assist you.

Long Term Care Program - Pre-Admission Assessment Process - Anyone seeking placement in a nursing facility or community residential facility may receive assistance and information from the Wayne County Area Agency on Aging. Those who will need financial help from Medical Assistance for nursing facility care must be referred to the Agency for a level of care determination. Agency staff specializing in long term care will complete required assessment procedures to determine the most appropriate, least restrictive level of care. This process, known as Options II Pre-admission Assessment, attempts to determine the most appropriate, least restrictive community living placement. Financial eligibility is determined by the County Assistance Office.

Changes brought about by OBRA (the Omnibus Budget Reconciliation Act of 1987) require the identification of individuals with special needs who are seeking admission to a nursing facility. Part of the Pre-Admission Assessment process is the identification of people with special placement needs, no matter what their financial status. Agency personnel provide a specialized assessment of targeted individuals - those with mental health diagnoses, mental retardation, or other related conditions - to facilitate determination of the most appropriate community care setting.

For more information about this process, please call the Agency's Long Term Care Community Health Nurse at 570-253-4262.

Policies

Appeal Policy - If an individual disagrees with the Agency's decision regarding a specific service, or feels that he/she has been treated unfairly by the Agency, that individual has the right to have his or her
grievance heard.

For more information concerning the Agency's "Appeal Policy and Procedure," please contact the Agency Ombudsman at 570-253-4262.

Donation Policy - Although there is no charge for Agency services, donations are often given by clients. Donations are used exclusively to defray the cost of Agency services and to provide additional services to
persons in need. Any donation made to the Agency, however small, is appreciated and most welcomed. All donations are gratefully received.

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