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Coordinating Care - AIS

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Coordinating Care - AIS

Care management programs assist older adults and their families with health and social services coming into their home.

For more information about Coordinating Care phone 800-510-2020 or send us an email.

Information about the services offered:

 

Linkages Program

For more information about the Linkages program send us an email.

Linkages case managers work with the client to find and coordinate services in the home. The Linkages staff members develop a care plan with the client and any significant others to help the client remain safe and as independent as possible. One common goal of Linkages staff members and clients is to prevent hospitalization or long-term, out-of-home placement.

Who is Served by the Linkages Program

Linkages serves clients who are "at risk" for needing placement outside their home. Many clients have difficulties taking care of several of their needs.

To Qualify for Linkages:

  • Age 18 or older
  • May or may not be Medi-Cal eligible
  • At risk of placement
  • Eligibility to other case management programs must be explored before screening for Linkages

Case Management Services Include:

  • Comprehensive assessment
  • Care planning with the client and family
  • Management of services
  • Coordination of care with other community agencies
  • Advocacy
  • Ongoing monitoring

What Is the Fee?

Clients who can afford to pay are requested to contribute to the cost of the case management; however, no eligible person is turned away solely from inability or unwillingness to pay.

Alternatives to Linkages

Professionals in our Call Center will evaluate for other possible AIS case management programs if clients are not appropriate for Linkages. Referrals might be made to private case management services.

 

Multipurpose Senior Services Program (MSSP)

For more information about MSSP send us an email.

The Multipurpose Senior Services Program is a care management service for seniors age 65 and older who are eligible for Medi-Cal and at risk of institutionalization.

Ironically, sometimes staying independent in one's home means getting help. That extra help with bill-paying, shopping, laundry and other tasks can keep someone from having to rely on family or leaving their own home.

MSSP care managers work with the client, family members and medical team to find and coordinate services in the home. Through the timely use of these services, MSSP protects both frail elders and California's budget from the cost of institutional care.

Clients Served by MSSP

The program serves clients in all regions of San Diego County. Most clients live in their own homes.

To Qualify for MSSP:

  • Age 65 or older.
  • Must be Medi-Cal eligible.
  • At risk of placement in a skilled nursing facility or intermediate care facility.
  • Clients usually have multiple health problems requiring the use and coordination of many community services.

Alternatives to MSSP

If someone is not eligible for MSSP, the Call Center professional will evaluate the candidate for other possible AIS care management programs, or refer the person to private-pay care management services.

What is the Fee?

There is no charge to the client or family.

Services MSSP Provides

Care management includes:

  • Comprehensive health and psychosocial assessment.
  • Care planning with the client and family.
  • Arrangement of services.
  • Coordination of care with other community agencies.
  • Advocacy
  • Some limited payment of in-home services.
  • Ongoing monitoring.
  • Annual reassessments.
  • Quarterly home visits and monthly contacts.

Who should know about MSSP?

  • Low-income, high-risk elders and their families.
  • Physicians.
  • Hospital discharge planners.
  • Social service agencies.
  • Home health agencies.

Who Makes a Referral?

Anyone can make a referral to MSSP, not just health care professionals. Call to apply.

 

Senior Options, Advocacy and Referrals (SOAR)

For information about SOAR, or to apply to the SOAR program, call or send us an email.

SOAR, formerly the Management and Assessment of Social and Health Needs (MASH) is a care management program that serves frail and disabled adults age 60 and older, who are at risk of nursing home placement and ineligible for other care management and in-home-care service programs.

SOAR is a program through the County of San Diego's Aging and Independence Services (AIS) that provides care management services to people who do not qualify for such services in other programs.

SOAR care managers work with the client to find and coordinate services in the home. The staff members develop a care plan with the client and any significant others to help the client remain safe and as independent as possible. One common goal for SOAR care managers and for clients is to prevent hospitalization or long-term, out-of-home placement.

There is a purchase of service component available within the program to provide assistance with homemaker, respite, escort, and money management services. SOAR clients whose monthly income and resources make them ineligible for In Home Supportive Services (IHSS) and unable to afford private-pay home care assistance may be eligible for purchase of services.

Clients Served by SOAR

SOAR care managers serve persons who are "at risk" for needing placement outside their home. Many of the SOAR clients have difficulties taking care of several of their needs.

To Qualify for SOAR

  • Age 60 or older.
  • May or may not be Medi-Cal eligible.
  • At risk of placement.
  • Eligibility to other case management programs must be explored before screening for SOAR.

Case Management Services Include

  • Comprehensive assessment
  • Care planning with the client and family
  • Arrangement of services
  • Limited purchase of services
  • Coordination of care with other community agencies
  • Advocacy
  • Ongoing monitoring

What Is the Fee?

Clients who can afford to pay are requested to contribute to the cost of the care management and purchased services; however, no eligible person is turned away solely from inability or unwillingness to pay.

Alternatives to SOAR

Professionals in our Call Center will evaluate other possible AIS care management programs if clients are not appropriate for SOAR. Referrals might be made to private care management services.

 

For more information about Coordinating Care phone 800-510-2020 or send us an email.