At PA Health Management, our focus is on increasing positive health outcomes and the quality of life of individuals in our community. We achieve this by spending time with each person one-on-one, building a supportive team and working to understand the details of each unique case. We help individuals reach medical and social goals and prevent issues and risks through identifying and addressing their root causes. PA Health Management is qualified through the Office of Long-Term Living (OLTL), Department of Human Services (DHS), to provide Service and Supports Coordination for eligible individuals throughout the entire state of Pennsylvania.

PA Health Management provides Service Coordination through the Managed Care Organizations (MCOs) chosen by the Department of Human Services to deliver Managed Long-Term Services and Supports (MLTSS). Supports available to individuals are specialized for a wide array of health and social needs, including and not limited to physical disabilities, mental disabilities, brain injuries, cognitive impairments, mental health concerns, individuals who are aging and more.

Pennsylvania’s Community HealthChoices Health Plans:

Supports Coordinators work with individuals and their families in several aspects.

Your Service Coordinator will conduct Comprehensive Needs Assessments to ensure goals are met while progression and new needs are documented in each individual’s unique Plan of Care (POC). This involves a variety of assessments and steps to deliver appropriate support. Communication and meeting often to evaluate progress are essential. Individuals may involve friends, family and advocates in their team meetings with their Service Coordinator who will assist with contacting and coordinating their Person-Centered Planning Team (PCPT).

At minimum, the following assessments and notes are documented for every individual approved for waiver services:

For the Community HealthChoices (CHC) Waiver:

• The Plan of Care (POC)
• The InterRAI
• The Patient Health Questionnaire (PHQ-9)
• Progress Notes

For the Attendant Care Waiver, ACT 150 Program, COMMCARE Waiver and OBRA Waiver:

• The Care Management Instrument (CMI)
• The Level of Care Assessment (LOCA)
• An Individual Service Plan (ISP)
• Progress Notes

The Service Coordination team assists individuals in locating and accessing services which may not be offered by their respective waiver or program, such as resources available in the community.

We communicate, monitor progress and ensure the individual at the center of care has team meetings to reevaluate effectiveness of their Plan of Care (POC). A Supports Coordinator will call at least once per month and visit in-person once per three months, or more often, to ensure that services are being delivered as outlined in their plan.