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CMO Stories
- One CMO member has a mild developmental disability with a strong
interest in auto mechanics. After high school he tried to take
some courses offered at the area technical college to achieve his
dream of becoming an auto mechanic. Due to his difficulties with
reading and writing this was not successful for him. Because of
the efforts of a number of people in his life to try to assist him
to work in the field he loves, his support team (CMO team,
technical college instructor, parents, DVR and others) was able to
set up a self-directed support model, which would give him the
opportunity to learn some specific repair skills using a hands-on
approach with job coaching. The technical college instructor knew
of a retired individual who was living in the area and formerly
worked in this field. This individual was very interested in
working with our member as a job coach. DVR contracted with
Lutheran Social Services to locate a job for our member and they
found an opportunity for him at Midas Muffler Shop. The CMO team
set up his job coaching under a self-directed support model in
order to get a job coach with specialized skills. Our member
started the job about a month ago and is doing very well so far.
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What is Family Care?
Who does Family Care
serve?
Aging and Disability
Resource Centers
Managed Care
Organizations
Where in Wisconsin
can you find Family
Care?
How do you apply?
Consumer resources
for questions
Real life stories
Why Family Care?
Being a Full Partner
in Family Care
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- A group of three Hispanic adult family members, all CMO members
who live together, expressed an interest in meeting new people and
socializing. Their interdisciplinary team made a referral to an
agency that offers group socialization activities. After getting
to know the group for a little while, one of our three members
offered to teach the group a salsa dance. It was such a big
success that she now teaches a class at a local dance club on
Tuesday afternoons.
- A younger member who resided in a nursing home for several years
because of a spinal cord injury wanted to live in a less
restrictive environment. He joined the CMO and the
interdisciplinary team was able to recruit an Adult Family Home
provider from nursing home staff. The provider already had a
professional relationship with the member and knew how to meet his
significant personal care and medical needs. In addition to
meeting his outcome of moving into the community, the member also
has been able to meet his goal to quit smoking with supports
provided by the CMO. The member is very happy with his present
living situation and is able to participate in social and
recreational activities. His Adult Family Home also has a teenage
son who provides a lot of social interaction. When he does not
travel with the family, respite comes into his new home to provide
the services he needs. He and the Adult Family Home have adjusted
well to the new living arrangement.
- A 57-year-old member had been residing at a nursing home for
almost 2 ½ years due to a motorcycle accident in fall of 2000,
which resulted in a brain injury and paraplegia. He went through a
rehabilitation program at the nursing home and made tremendous
progress. He became independent in doing as much of his self-care
as he could. He is able to drive a scooter independently in the
community. With his progress made at the nursing home, the
interdisciplinary team (case manager, R.N. case manager and the
member) discussed the possibility of moving out of the nursing
home to a less restrictive setting. While the member had not
progressed to the point of independent living, the idea of moving
to a home was exciting to him. However, there were some barriers
that he faced when looking at moving to a less restrictive
setting. Some of those barriers were his needs of requiring an
intensive bowel program, his need to be transferred by a lift, and
a reoccurring skin ulcer. The CMO referred the member to multiple
less restrictive settings in the community, all of
which were unable to meet his needs due to his level of care.
Rather than becoming totally discouraged, we continued to forge
ahead looking for a placement. It was at this time we learned of a
provider willing to create a setting that would meet the member’s
outcomes. They created a home for him with staff available to meet
his needs. He lives with three other men. He was discharged from
the nursing home in February. He was very excited about moving
there and has been doing very well.
- This is the story of a 47-year-old gentleman with
developmentally disabilities who moved from a local ICF/MR to a
four-bed Adult Family Home. Due to an injury many years ago at a
supported employment job, his main mobility aide is a wheelchair.
Originally, this member lived in an Adult Family Home, however he
experienced some serious medical complications that resulted in a
hospitalization. Due to the hospitalization, the Adult Family Home
he was residing in would not accept him back because of the level
of care he required. The main medical complication the team
observed was a decline in his ambulation. As a result, he was
unable to transfer and was also unable to take a bath
independently. At the time of the hospitalization he was diagnosed
with a kidney infection and urinary sepsis. It was decided he was
in need of more skilled nursing care and the team and member chose
an ICF/MR. While at the ICF/MR, nursing staff and the physical
therapy staff worked on getting our member stronger and healthier.
That they did! With intense commitment from the member and the ICF
staff, he was able to transfer with assistance and was doing many
of his activities of daily living skills independently or with
minimal assistance. At this point the team, along with the member
and his guardian, believed he was ready for community placement.
The team made a referral to a new residential provider interested
in developing in the area to meet the needs of our more physically
challenged members. This provider has built a brand new house,
completely wheelchair accessible. Our member loves having his own
room for his personal belongings and also having cable TV. It was
great to see this member come so far and being able to reside in
the community once again.
- Five years ago a man with developmental disabilities moved from
a home and community based waiver county to a Family Care county.
When he lived in the other county, he had not been successful in
competitive employment or in living in the community. The
vocational agency there had "given up" with community
work placements and the man was working in a sheltered workshop.
Since this man moved to a Family Care county, he has worked in the
same community job for four years. He met a woman with
developmental disabilities and they were married last year. They
now live in a home the man purchased.
A 71-year-old CMO member, who has congestive heart failure,
diabetes, obesity, thyroid problems, sleep apnea, osteoarthritis and
osteoporosis, enrolled in Family Care in April 2002. The member
resides in her own home, which has had home modifications as part of
her member-centered care plan. The home modifications have helped
the member become more independent. She has the assistance of a
supportive home care provider twice a day and home-delivered meals.
The member has been extremely motivated to lose weight in an effort
to improve her health. Through diet and physician approved exercise,
the member has lost 95 pounds. The weight loss has allowed the
member to be taken off or reduce some of her prescription
medication, become more mobile and improve her self-esteem. She is
extremely motivated to continue to lose weight through walking and
participating in a water exercise class at the local YMCA. The
member’s doctor believes that continued weight loss will allow her
to no longer require 24-hour use of oxygen.
- This is the story of a woman with developmentally disabilities,
who the CMO care manager had met originally back in 1999 before
the Family Care program was implemented. At that time, the woman
didn’t feel safe where she was living. She also had a
representative payee who was supposed to be helping her with her
financial affairs, but the client felt she was mismanaging her
funds. When the woman enrolled in Family Care, the care management
team worked with the member to address her immediate goals of
physical and financial safety. The woman moved into an apartment
of her own, and a new representative payee was found to help her
with her financial needs, bill paying, etc. With those immediate
goals achieved, the care management team and the member then
turned their attention to considering what the member’s
long-term dreams and goals were. As part of this process, a
"PATH" session was set up for the member.
"PATH," which stands for Planning Tomorrows with Hope,
is an eight step person-centered planning tool that utilizes a
person’s dreams to help them develop a practical action plan to
move towards those dreams. As a result of this member’s
"PATH" session, the member identified a desire to manage
her own money. The care management staff worked with the member to
prepare a member-centered plan, to identify what was needed to help
her achieve her goal, and to help her take the necessary steps. This
included taking classes at the job center, brushing up on her math
skills, learning to use a calculator, and other related activities.
The member actively pursued each of these. The member has been
handling her own funds since December 2002 and is doing well.
RC Stories
- As the role of aging and disability resource center staff in
transitioning people from the child to adult service system has
grown, so too has staff awareness of the challenges involved. This
is particularly true of their work with young adults who have
never been officially determined "disabled" for the
purpose of receiving public benefits and whose full-scale IQ
scores are just a little too high to warrant an immediate
disability determination. Supported employment of some duration is
needed before it is possible to determine whether employment in
the competitive workforce is even a possibility. It seems like a
"Catch 22" situation when an individual is not clearly
"disabled" via confirmation by the Disability
Determination Bureau and yet, without that designation, may be
unable to receive services that could either move him or her
toward self-sufficiency or provide additional evidence of a
disability.
Helping these people to achieve positive outcomes most often
involves a referral to the disability benefit specialist (DBS).
The DBS collaborates with medical providers, the Division of
Vocational Rehabilitation, supported employment providers, service
coordinators, and others as deemed necessary to gather the
information needed to assist the consumer. The DBS commits an
extensive amount of time and effort toward a goal that will take a
long time to reach and may never be achieved at all. The potential
benefits to the individual over a lifetime are deemed sufficient
to warrant the time and effort.
In March 2003, confirmation of a positive decision by an
administrative law judge in one such case represented a huge
success to ADRC staff.
Ms. M was referred to the resource center in June of 2000. She was
21 years old and had been denied Social Security and Veterans
benefits as a dependent. Ms. M graduated from a high school
program for people with cognitive disabilities and was receiving
supported employment services. At the time of the referral, her
parents were planning to move out of the state and Ms. M felt
that, as an adult, she could choose not to move with them. Her
preference was to stay in the area. However, she had no means of
financial support. Fortunately, Ms. M’s parents remained in the
area and provided substantial support during what turned out to be
a very lengthy process. Ms. M was also able to enroll in Family
Care. Though she wasn’t eligible for Medical Assistance, case
management services were needed to arrange and provide
follow-along in regard to supported employment.
An initial application for SSI as an adult was filed in July of
2000 and the request was denied in November of 2000. A
reconsideration request was filed in January 2001. Notice that the
reconsideration request had been denied came in February of 2002.
There was no explanation as to the reason for the delayed response
to the reconsideration request. Fortunately the new DBS was a
"quick-study"; a request for a hearing with an
administrative law judge was filed in April 2002 and a hearing was
scheduled for October 2002. The DBS represented Ms. M on her own
and left the hearing with little confidence that her efforts would
result in success. Notice of a fully favorable decision in April
of 2003 (nearly three years after the initial application) was a
welcome surprise to Ms. M, her family, the DBS, other ADRC staff
who have been involved, and the CMO service coordinators; all of
whom know the expanded possibilities available to Ms. M and her
family as a result of receiving SSI and Medical Assistance!
- The ADRC received the following e-mail as the very busy and
hectic quarter drew to a close:
Dear I&A Program Coordinator,
I am finally writing to thank your staff for their advice and
follow-up concerning my parents. After two days at my parents,
cleaning and trying in vain to convince them they needed some
help, we visited the resource center, feeling rather desperate. We
spoke with an information and assistance specialist, who
eventually took our concerns seriously and also gave us two good
recommendations, which we acted on: Talk to someone at our parents’
church and perhaps contact S…Associates or another such agency.
Several days (and much angst) later, I received a long distance
call here from one of your social workers who said he was on his
way to try to speak to my parents and, if possible, enter their
home. I explained that we had finally been able to make
arrangements with S…Associates so his visit should not be
necessary, but thank you. He called back 30 minutes later to say
he had checked with S… and they had promised to keep a close tab
on things and assure me (without my prompting) they are a very
reliable association.
I would like to tell you that my brother and I (were) very
impressed with your organization – their concern for the rights
and well-being of the elderly, the good advice and the quick
follow-up a few days later. It is such a relief that arrangements
have been made to keep our parents safely in their home for now.
Kudos to the resource center – a big "thank you" for
your assistance with such an important and stressful transition.
- An elderly couple was referred to the ADRC by a housing
development. The couple did not get long with other tenants, and
were engaging in verbal altercations on a regular basis. Both the
man and the woman were experiencing problems with incontinence of
bowel and bladder, further alienating them from the other tenants.
The landlord threatened eviction unless something could be done.
The couple was unwilling and possibly unable to acknowledge that
their behaviors were causing problems. (The couple appeared to
have beginning stages of dementia.) The ADRC worked with them for
approximately six weeks to effect basic change. The couple agreed
to let their adult children become involved and be informed of
their housing difficulties. The adult children were not aware of
their parent’s situation and their declining abilities to cope
with day to day activities. The children took a pro-active stance
and helped their parents find other housing, as the situation
between their parents and the other tenants was irreparable.
- An elderly gentleman was referred to the ADRC as a pre-admission
consultation. He entered a nursing home because of an exacerbation
of congestive heart failure. He also had a significant mental
illness and due to this he had stopped taking his heart medicine.
He had been living alone with only family supports. A family
member was his guardian and they were very concerned about him
trying to go back to his former living arrangement. They were
unaware that there was help or other living arrangements that
would meet his needs. At the time the PAC referral was made it was
very appropriate that he be in a skilled nursing facility. The
ADRC met with the guardian and outlined various options that were
available based upon his medical condition. The guardian agreed to
get back in touch if the gentleman’s situation improved. Within
a period of time the guardian had to apply for Medical Assistance
and the economic support worker encouraged the guardian to
re-contact the ADRC, which she did. The ADRC established
functional eligibility and facilitated enrollment in the CMO. The
gentleman has left the nursing home and moved into an apartment
setting where his medications can be monitored, meals are provided
and there is a built in natural support network.
- The ADRC recently worked with an area high school regarding a
19-year-old male who is in their special education program and a
senior this year. The school crisis counselor called on Wednesday
asking for help and didn’t know where to get assistance. The
school was informed that morning that the student was now
homeless. His parents had moved out of the state at the beginning
of the school year and he was living with a friend’s family, but
the living situation changed suddenly and he felt it was no longer
safe to stay there. He was receiving SSI, but when he turned 19
years old he stopped received it. He also had been working on
another friend’s farm during the school year, but he was kicked
by a farm animal and hurt his shoulder. The physician instructed
him not to work until it was healed. The counselor was now dealing
with a homeless young adult, who is in special education, with no
income, unable to work at his regular job, and with no parents in
the immediate area for support. I informed the counselor that I
would check into possible services and options for him and would
call her back. I discussed with my supervisor referring him to
Family Care for urgent services, the Disability Benefit Specialist
program to assist him with assessing his SSI status, and adult
protective services. After assuring that he had a place to stay
that night, we set up a time to meet the next day with the
student, crisis counselor, and two case managers from Family Care.
The disability benefit specialist was also able to set up an
appointment to meet with him regarding his SSI.
The counselor, case managers, and myself met with this young man
at the high school on Thursday. I informed him of his options,
including urgent services through the Family Care program, adult
protective services, Disability Benefit Specialist services and
potential foster care homes. He was agreeable to these. He had a
place to stay over the weekend and he would meet the new foster
parents on Monday. He seemed relieved to have the help and was
willing to work with all of us as needed. He was able to move into
his new foster home on Tuesday and enroll in Family Care. His case
managers then assisted him with settling in and hooking up with his
appointments as needed. This young man was thrilled to have such
good meals at his new foster home, and commented on what a good cook
his foster mother was. When I last saw him I noticed that he was
gaining weight and beaming from ear to ear. He reported he was able
to do chores at his new foster home, giving him some spending money.
With this support, he will be able to finish up the school year and
pursue his career choice of enlisting in the armed services.
Last Revised: July 21, 2009
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