Community Resource Connection

Community Resource Connection: an individual home care plan

A useful resource is one that fits the person's need and is actually available. Home health social work can discuss relevant community options and application questions without promising eligibility, funding or a place in a program.

Resource-needs assessment

Resource navigation starts with a defined unmet need. The social worker considers how that need affects the home health plan and what support already exists. A list of program names is not enough if the household cannot use them or their information is out of date.

Program information review

Potential resources have their own eligibility, application processes and availability. The responsible program must confirm those details directly. A home health professional cannot approve another agency's benefits or guarantee a place, funding or accommodation. With consent, family members may help gather the information the program requires.

Eligibility question support

The discussion should remain practical. Language, access and support limitations may affect which questions need to be asked. If one option cannot help, alternatives may be considered without promising that they will be available. Resource work supports the recovery arrangement while ordered clinicians continue to address movement, daily activities and medical needs.

Related care for community resource connection

Medical Social Worker at Home. Care Coordination at Home.

Eligibility and insurance review

Original Medicare Part A & B may cover eligible home health care when the applicable homebound, skilled-care, clinician-order and certification requirements are met and services follow an individual plan through a Medicare-certified agency. Coverage and any patient responsibility require verification. Blue Shield of California PPO and Anthem Blue Cross PPO benefits are also reviewed individually. Equipment, medications and separately billed services require their own benefit review.

To discuss community resource connection in Los Angeles County, contact HarvardCare Home Health with the current clinical instructions and the tasks that need support. Referring clinicians can use the patient referral page. Assessment, service availability and individual eligibility determine the next steps.