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Case Management

Care & Service Coordination

Care coordination enables individuals to access services and benefits that ensure their independence and enhance their quality of life.  

About Our Care & Service Coordinators

Care & Service Coordinators maintain regular contact with individuals to monitor services and assess for additional needs. They have established effective, collaborative partnerships with community organizations, providers, and state agencies to better serve the needs of older adults. As important decisions or changes arise, we connect you with the necessary resources to make informed decisions.

Whether you are a family member or professional, we will create a cohesive support system, administering the best care possible while keeping the client at home, where they want to be.

My name is Erin Roelke and I’m the Director of Care and Service Coordination at Age Well. Care and Service Coordination, the department encompasses actually many different programs at Age Well, including our Helpline, state health insurance program, community health work program, options counseling, caregiver support and Care and Service Coordination, which we also call case management. So I’m actually going to leave it to my colleague Sam Carlton to talk more about the Helpline and State Health Insurance Program. So I would really encourage any volunteers to also think about the Helpline as a resource for themselves or their loved ones or as you’re interacting with clients, it is a great place to just go and ask questions if you’re not sure about what someone may need. So I do want to talk a little bit more in depth about the different programs that we have within Care and Service Coordination. I mentioned community health work and options counseling. Those are both two short-term services that can be delivered either in the home or can be provided through over-the-phone counseling with clients, but they’re really both meant to provide assistance and access with different public benefit resources or resources that are available in the community. Community health work is really focused on helping clients to access public benefits and other programs. So for example if we get a call on the Helpline from a client who is looking to apply for the three squares program and they need a little bit more help with going through that application process a community health work referral is a great referral for that person because they can provide a little bit more of that in-depth assistance versus options counseling which can either be for resources that someone is looking for access to now or for long-term planning. So for the long-term planning side the example that I usually give is somebody who maybe was recently diagnosed with a chronic health condition or a degenerative disease like Parkinson’s disease who doesn’t have care needs now but is anticipating that they might need connection to care resources in the future. An options counseling referral now is actually a great idea for someone in that situation who can understand then what resources are available for them in the future and any steps that they might want to take now while they’re considering that. Our caregiver support program is also a great resource and while many of the programs that we’re talking about help caregivers by helping the person that they’re caring for if you are a caregiver for someone who has long-term care needs or you know someone who is a long-term caregiver. You know that’s an extremely taxing job and we want to provide as much support as we can. So we do have a dedicated caregiver support specialist who can provide access to peer support resources talking through education around what the individual that they’re caring for is really needing help with and helping to access respite programs. So there’s a couple of different ways that we do that we do have a dementia respite grant program which can help provide funding to pay for respite services and we also have a respite squad but Erica will talk more about that. One of the other programs that we have that I mentioned is Care and Service Coordination and that’s a very large program it’s usually referred to by clients and Care and Service Coordination staff as Case Management. That program is really providing long-term support with coordinating services helping to help clients to access resources and it could be clients who are on a care program or who are not on a care program but do have some ongoing needs. That’s a really important one I think for anyone who’s in the volunteer space to understand because you may be seeing a client through your volunteering work who does have a care and service coordinator and that’s a great resource for you to connect with, as well as they’re seeing that client usually on a monthly basis and helping to organize some of those supports. You may also see clients who you think really would benefit from Care and Service Coordination, and that again would be a great call to the Helpline or calling one of your supports in the volunteer department to talk about what those clients needs are. We have a couple of programs within care and service coordination that are also really specialized. So we have a new American team that supports our new American community, particularly here in Chittenden County and we also have a specialized care and service coordination team. They have smaller caseloads but they tend to work with clients with more acute needs that could be related to mental health or complex medical diagnoses one thing that I think is important to talk about just a little bit is that we do provide services for  clients who are self-neglecting so if you’re out in the community and you’re working with clients through your volunteer work with Age Well and you see  some concerning things that make you think that a client may need support that is a great thing to talk about with the volunteer department or with the helpline particularly if you’re seeing a client who may have seemed to decline recently either in their personal  hygiene or the state of their home or you’re seeing them changes in their behavior or weight loss those are things that our specialized care and service coordination team might be able to provide more support around particularly if there are some underlying diagnoses that are causing those changes.

Veteran Directed Care

Allows veterans who require help with activities of daily living — for example, bathing and dressing, medication, and financial management– to receive services and support in their home.

Services Provided

Age Well’s Care & Service Coordinators provide the following services for individuals and caregivers:

  • Assistance with applications for 3SquaresVT, Medicaid, Fuel Assistance, pharmacy programs, SSI, Medicare, supplemental insurance, housing options, and other benefit programs
  • Help with completing healthcare and financial powers of attorney documents  
  • Assessments for  in-home care services, durable medical equipment, home modifications, adaptive equipment, and Meals on Wheels 
  • Information about support groups, caregiver training programs, and respite services in the community
  • Referrals for nutritional assessments, depression or grief counseling, and volunteers/Senior Companions for friendly visits
  • Access to Options Counselors to explore alternatives for care and eligibility criteria for long-term care 
  • Options for long-term care services in their homes and elsewhere
  • Support with making decisions about the care needed to help family members in-home and residential settings

“It’s people like [our Care & Service Coordinator] that help us, as a family, cope with the changes and decisions that have to be made for our loved ones. She’s like a dear friend coming to sit at the table and help us through the steps. I wouldn’t have known where to turn without her.”

– Brenda

Contact Us

Call the Helpline at 1-800-642-5119 for more information about Care & Service Coordination.