Case Management

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Home Health

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Provider Service

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Hospice

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ABOUT US

Our Case Managers are dedicated to providing optimal case management services that will allow individuals to appropriately manage their health care and daily living needs, while living independently in their own home.


WHO WE SERVICE

Peters Agency provides Case Management services for Low Income, Frail, Elderly or Disabled adults who have been authorized to receive services through State funded Medicaid Waiver program such as: ADvantage, My Life My Choice, Sooner Seniors, Medically Fragile or the Living Choice Demonstration Project by either the Department of Human Services or Oklahoma Health Care Authority.

 

The Role of the Case Manager

· Provide Member Support and Advocacy

· Research and Educate the member and caregivers on all available Formal, Informal and Community Resources that can assist meeting needs;

· Collaborate with the member, family and the healthcare team to develop a cost effective, individualized and comprehensive care plan that will assist in the management of the member’s medical diagnosis, as well as the member’s daily living needs.

· Develop and Implement an Individualized Outcomes Based Care Plan.

· Coordinate/Facilitate Delivery of Services.

· Monitor and Assess the Care Plan to assure that the members needs are being appropriately met.

· Facilitate team meetings with the member, family and health care providers to discuss changes in the member’s health care or needed revisions to Care Plan.


Living Choice Demonstration Project

Peters Agency Case Management also provides Transition Coordination Services for Participants of the Oklahoma Living Choice Demonstration Project. The Oklahoma Living Choice Demonstration Project is a grant that is administered through the Oklahoma Health Care Authority. Through the Living Choice Project, funds are allocated to be utilized for the transition of individuals out of the Nursing Home Facility and back into the Community.


The Role of the Transition Coordinator

Establishes a rapport with the nursing home staff, reviews medical records and collaborates care needs with the Participant, Facility Administrator, Physician, Caregivers and Healthcare Based Community Plan that will be meeting the Participant's physical, mental, psycho-social and daily living needs.

• Locates and Utilizes Living Choice funds to assemble a permanent resident within the community that will safely meet the Participant's needs.

• Coordinates and facilitate a meeting with community Healthcare services to establish care that will appropriately meet the participant's daily living and medical needs on the day of community transition.

• Educate the Participant on all community resources available to meet his/her needs within the community setting.

• Facilitate and Coordinate the delivery of services by all service providers.

• Monitor and Assess the community plan to assure that all participants needs are being met.

• Provide participant support and advocacy to assist with meeting the participants needs and keep them safe in his/her home.