Pathway To Serenity Case Management, LLC
Services
Service Counseling
Service counseling involves objectively consulting, discussing, advising, and listening. The CLTC Case Manager is in a position to confer with the participant and/or Authorized Representative concerning needs and to provide information that will assist them in making sound long term care decisions. The service counseling process includes educating the participant and/or Authorized Representative with the long term care options available to them and ensuring the participant's right to be involved in planning the care.
Service Planning
Person-Centered Service Planning is the active, on-going process of working together with the participant and/or Authorized Representative to assure the efficient provision of services.
Service Coordination
Service coordination is a vital component of case management and must be documented. The Case Manager works together with the participant, and/or Authorized Representative and other agencies involved in the participant's care to ensure services: • are appropriate for the participant's needs; • meet acceptable quality standards. Participant are not duplicated; • are cost effective alternatives; • maximize the utilization of available resources; • are provided by other agencies in accordance with maintenance of effort agreements • augment, not replace, the participant's informal support system.
Monitoring; and Re-evaluation
The Case Manager monitors the plan for each waiver participant at least monthly. Monitoring should be accomplished through contacts with the participant and/or Authorized Representative. If the Case Manager is unable to contact the participant and/or after three (3) attempts on different days, at different times, within 10 business days, approval may be obtained and documented in the Phoenix narrative from the Lead Team Case Manager, Lead Team Nurse Consultant or Area Administrator to make the required contact with the Authorized Representative.