"Home Is Where The Care Begins"

Carolinas Home Care Agency, Inc.  

Targeted Case Management/IDD

This is a service for adults and children five years of age and older who have intellectual and Development Disabilities or children of less than five years of age who receive funding through a CAPMR/DD Waiver.

Carolinas Home Care Agency, Inc. Case Management (I/DD TCM) is an activity that assists recipients to gain access to necessary care: medical, behavioral, social, educational, and other services appropriate to their needs. Case management is individualized, person centered, empowering, comprehensive, strengths-based, and outcome-focused. The functions of case management include.

  • Case Management Assessment
  • Person Centered Planning
  • Referral/Linkage and
  • Monitoring/follow-up


Case Management Assessment shall include

Carolinas Home Care Agency, Inc. comprehensive and culturally appropriate case management assessment documents a recipient’s service needs, strengths, preferences, resources, and goals to develop a Person Centered Plan. The case manager/Qualified Professional shall gather information regarding all aspects of the clients which includes but limited to psychosocial, behavior, medical, physical/functional, financial, social, cultural, environmental, legal and vocational/educational areas.
This case management assessment integrates all current assessments including the comprehensive clinical assessment, psychological assessments, and medical assessments, including assessments and information from CCNC (if applicable) and the primary care physician. This case management assessment shall also include early identification of conditions and needs for prevention and amelioration.

In addition, the case management assessment involves consultation with other natural and paid supports such as family members, medical and behavioral health providers and educators to from a complete assessment. The case management assessment includes periodic reassessment to determine whether a recipient’s needs or preference have changed. Reassessment occurs at least annually as part of the person centered planning process.

Person Centered Planning

Person centered planning promotes recipient self-direction and self-management. Qualified Professional/Case Manager uses the information gathered during the case management assessment and ensures the active participation of the recipient and his or her caregivers in the person centered planning active participation of the recipient and his or her care givers in the person centered planning process. The person centered planning procvess involves information exchange between the recipient and his or her supports in order to help the recipient make informed decisions.

Person centered planning is an ongoing process that drives the development and periodic revision of a specific service plan based on the information collected from the person, family, other personal supports, and assessments or reassessments. The person centered plan is comprehensive and addresses the recipients identified needs, strengths, resources, and preferences as identified in the case management assessment. The person centered plan specifies the client’s goals and the actions necessary to address the medical, behavioral, social, educational and other service needs of the recipient.

Person centered planning includes the active participation of the recipient and the client’s natural paid supports. The goal of person centered planning is to assist the person to obtain the outcomes that they desire by developing action plans that will help the person achieve their goals. A recipient’s person centered plan is revised as his or her abilities, needs, preferences, and goals changed.

Referral/Linkage duties

Carolinas Home Care Agency, Inc. referral and linkage activities connects a recipient with medical, behavioral, social and other programs, services, and supports to address identified needs and achieve goals specified in the person centered plan. Referral and linkage activities include but are not limited to:

  • Coordinating the delivery of services to reduce fragmentation of services and supports and maximize mutually agreed upon outcomes.
  • Facilitating access to and connecting recipients to services and supports identified in the person centered plan.
  • Making referrals to providers for needed services and scheduling appointment with the recipient.
  • Assisting the recipient as he or she transitions through levels of care
  • Facilitating communication and collaboration among all service providers and the recipient
  • Assisting the recipient in establishing and maintaining a medical home with a Community Care of North Carolina (CCNC) Physician or other primary care physician.
  • We receive referrals from family members, clients, Department of Social Services, Screening Triage Referral from LME, Hospitals, and other service providers etc.


Monitoring/Follow-up of clients

Monitoring and follow up includes activities and contracts that are necessary to ensure that the Person Centered Plan is effectively implemented and adequately addresses the needs of the recipient. Monitoring activities may involve the recipient, his or her supports, providers, and others involved in services/support delivery. Monitoring activities helps determine whether:

    • Service are being provided in accordance with the recipient’s person centered plan
    • Services in the Person Centered Plan are adequate and effective
    • There are changes in the needs or status of the recipient and
    • The recipient is making progress toward his or her goals.