The Community Choices program provides a service plan to frail elders who otherwise are at imminent risk of nursing facility admission or who would not be able to be discharged from a nursing facility without these services.

The program can provide community-based services to frail elders at a significantly lower cost than nursing facility care.

A MassHealth member age 60 or older fits the Clinical Criteria if the member is enrolled in the Waiver and meets one of the following:

• Was actively seeking nursing facility care within the last six months
• Recently experienced a serious medical event, regression in physical or cognitive functional ability or a cumulative deterioration in functional ability
• Was discharged from a nursing facility within the last thirty days
• Is at risk of nursing facility admission due to the instability or lack of capacity of informal or formal supports.

• Needs 24 hour supervision because of complex health confitions; or
• Experiences a significant cognitive impairment; or
• Is unable to manage/administer prescribed medications; or
• Experiences frequent episodes of incontinence; or
• Requires daily supervision and assistance with multiple Activities of Daily Living (ADLs)

Enrollment Process

Boston Senior Home Care works with local organizations, including hospitals, visiting nurse associations, skilled nursing facilities, etc, to identify potential enrollees for the Community Choices program. Boston Senior Home Care does this through an interdisciplinary approach that will:

• Conduct a needs assessment
• Determine eligibility
• Work with the client and his/her family to determine a service package that would include both waiver and Medicaid State Plan services
• Coordinate all services, including communicating to any State Plan service provider that may also be serving the client and requesting that any change in the scope or duration of State Plan services be communicated to Boston Senior Home Care
• Conduct on-going interdisciplinary case management activities, including in-home reassessment home visits as needed and at least once every 3 months
• Conduct a reassessment of the status of the client at every home visit or during any other contact with the case manager or nurse; this includes any changes in client's status, eligibility for the Choices Program and need for continued or additional Community Choices services
• If, upon reassessment, it is determined that a Community Choices client no longer meets the clinical criteria of the program due to an improvement in their condition OR no longer requires the intensity of Waiver services provided by the program, Boston Senior Home Care shall determine the suitability of placement in other agency or community programs
• Each discipline documents all communication devoted to case management and nursing supervision for each client

Enrollment

To enroll or to make a referral, call Boston ElderINFO at 617-292-6211 and ask about Community Choices.