What is LTSS Service Coordination?
Long Term Service and Supports Service Coordination will assist individuals living in the community to gain access to services and supports that meet their needs, most often referred to as waivers. The LTSS Service Coordinator works together with individuals and their person centered planning team to identify, coordinate, and facilitate all necessary services regardless of the funding source.
What happens during LTSS service Coordination?
The Service Coordinator (SC) works to develop a partnership of respect, support, and collaboration with the person served and the team they identified. Within this partnership, the service coordinator develops a person centered service plan (PCSP) with the help of the participant and their team. The PCSP is based on the participant’s strengths, needs, abilities and identified risks, which are used to develop measurable goals, outcomes and actions to achieve them.
The LTSS Service Coordinator provide any of the following services:
- Aligning resources with the participant’s needs, goals, and preferences.
- Actively coordinating with other individuals and/or entities essential in service delivery for the participant, including linking participants to community resources, services and programs, and formal and informal supports, and any other resources.
- Providing ongoing assistance in gaining access to needed services, including transportation services, employment or housing needs, as well as physical and mental health treatments.
- Coordination with persons or entities providing services and supports.
- Developing and updating a person-centered service plan that considers a person’s needs and routine activities to ensure an appropriate amount of services and supports are coordinated.
- Monitoring the individual service plans to make sure treatments remain appropriate. SCs help participants determine whether their service plan is not only meeting their needs but also working towards their hopes in life.
- Coordinating transitions to and from settings, including communication between providers and participants and/or representatives.
Meeting with my Service Coordinator
Your SC is mobile and can offer outreach in whatever setting the participant prefers – home, community or SAM office – and allows for the best interaction with the participant.
The SC can adjust the intensity and frequency of services provided according to the needs of the individual as identified in his/her person centered service plan, particularly during times of transitions or crisis. The SC will also review the level of care needs of the participant periodically to ensure that needs are being met.
Who is Eligible for LTSS Service Coordination?
Individuals who are determined as eligible for home and community-based services. This includes any eligible person above the age of 18 with a disability, who qualifies for a nursing facility level of care but wants to remain in their home. Eligibility for service funding through various waivers is determined by age and level of need and disability, including disabilities that impact self-care, mobility, self-direction, and the capacity for independent living, which may include the ability to manage financial and legal affairs.
What type of Waivers are there?
- Community HealthChoices Waiver
For more information on Long Term Services and Support please contact us at:
Toll Free: 1-877-360-8355