This appendix describes terms in this Service Coordination Partnerships Toolkit that are often used in service coordination activities across systems—including those for housing, aging, disability, and health.
Service Coordination
Many people with disabilities and older adults need a combination of housing and supportive services (see About Supportive Services [LINK to segment below]) to continue living in their homes. Person-centered service coordination allows individuals to choose which, if any, services they want to apply for or access. For this toolkit, service coordination is a broad term encompassing activities that support individuals in identifying and connecting with services and supports they need and want in the community. Housing, aging, disability, and health systems use a variety of service coordination terms and definitions. Whether called “service coordination” or another related term, the main activities of service coordination include:
- Learning about a person’s needs and their preferences for supports and services that might meet those needs in the community.
- Helping gain access to people, organizations, and programs that can help individuals meet their needs in their preferred manner.
- Working together with the individual to document their goals, strengths, needs, and preferences and to identify which community supports will be most helpful in meeting those goals and needs, resulting in a person-centered and consumer-driven service plan.
- Assisting individuals in the community with program applications and enrolling in service programs.
- Following up with a person to learn whether their plan is being carried out as they envisioned and offering assistance or changes to help resolve any challenges.
Active verbs that describe service coordination include “learning about, helping access, determining eligibility for, identifying preferences with, figuring out together, building on, assisting with, and following up with.”
To support cross-system understanding, the table below offers definitions for the following common service coordination terms: care coordination, care management, case management, options counseling, and person-centered counseling. These federal agency definitions are applied to this toolkit.
Service Coordination Common Terms
| Term | Definition |
| Care Coordination |
Care coordination is the organization of an individual’s care across multiple health care providers. Care coordination involves deliberately organizing an individual’s care activities and sharing information among all the participants concerned with an individual's care to achieve safer and more effective care. (Source: HealthCare.gov) Care coordination is a term often used across managed care organizations when providing services under a Medicaid Managed Long-Term Services and Supports (MLTSS), Dual-Eligible Special Needs Plan (D-SNP), or accountable care organization (ACO) contract. Other integrated care models, such as the Program of All-Inclusive Care for the Elderly (PACE), also use care coordination. Staff providing care coordination are often called care coordinators. |
| Care Management |
Care management is a team-based, person-centered approach designed to assist individuals and their support systems in managing medical conditions more effectively. It also encompasses those care coordination activities needed to help manage chronic illness and disability. (Source: Agency for Healthcare Research and Quality (AHRQ)) Care management is a term often used within health homes, medical homes, patient-centered medical homes, and other health care models including primary care and managed care. Staff providing care management are often called care managers. |
| Case Management |
Case management is a collaborative process that involves assessing, planning, implementing, coordinating, monitoring, and evaluating the services and resources required to meet the health and social care needs of a person. (Source: Administration for Community Living (ACL)) Note: Sometimes the terms care management and case management are used interchangeably. Care management often focuses more on health care, whereas case management often entails coordinating services beyond health care. (Read more at ChartSpan.) Staff providing case management are often called case managers. |
| Options Counseling |
Options counseling is a person-centered, interactive, decision-support process whereby individuals are supported in their deliberations to make informed long-term support choices in the context of their own preferences, strengths, and values. (Source: State of Montana Department of Public Health & Human Services) Options counseling is provided by staff working at aging and disability resource centers (ADRCs), area agencies on aging (AAAs), centers for independent living (CILs), and other community-based organizations. Staff providing options counseling are often called options counselors. |
| Person-Centered Counseling |
Person-Centered Counseling is a process where a trained professional within a community-based organization assists an older adult or person with disability with any immediate long-term services and supports (LTSS) needs, conducts conversations with the individual to confirm who should be part of the process, and identifies goals, strengths and preferences. A comprehensive review of private resources and informal supports is conducted. The professional then facilitates:
Person-centered counseling is provided by staff working at aging and disability resource centers (ADRCs), area agencies on aging (AAAs), and centers for independent living (CILs). Person-centered counseling is often used interchangeably with options counseling. The Administration for Community Living (ACL) No Wrong Door initiative began using the term options counseling but later adopted the term person-centered counseling. Staff providing person-centered counseling are often called person-centered counselors. |
About Supportive Services
Disability, aging, and health organizations offer a myriad of services that assist individuals with obtaining or remaining in the housing of their choice. Service coordinators, person-centered options counselors, peer counselors, care coordinators, and care managers assist individuals with applying for and accessing the services and supports that they need and want. Some examples of supportive services include the following (this is not an exhaustive list):
Care Transitions
- Community transition services
- Hospital discharge planning and support
- Transition-out-of-institution services
Caregiver Supports
- Caregiver support programs
- Peer supports
- Respite care and day services
Coordination Functions
- Care coordination
- Care management
- Person-centered planning
Housing Supports
- Assistive technology
- Environmental and home modifications
- Eviction prevention support
- Housing counseling and navigation
- Pre-tenancy services, such as housing search and applications
- Post-tenancy services, such as care management and skills training
Meal and Nutrition Services
- Congregate meal programs
- Healthy food home deliveries
- Nutrition education and counseling
- Nutrition services, including home-delivered and medically-tailored meals
Navigation Functions
- Benefits enrollment support
- Information, referral, and assistance
- Person-centered counseling and options counseling
- Translator and interpreter services
Personal Care Services
- Homemaker and chore services
- Independent living skills training
- Personal care assistance
Screening and Assessment Functions
- Functional assessments
- Screening for whole-person health needs
Transportation
- Transportation coordination
- Transportation services (medical and non-medical)
Other Supportive Services (Source: ACL)
Employment and Specialized Supports
- Employment supports
- Veterans' services
Health and Wellness Services
- Evidence-based and chronic disease self-management programs
- Social support
- Trauma-informed services
- Wellness programs
Information and Legal Services
- Legal services
- Health insurance and benefits counseling
(Sources: Che and Cheung, 2024; ACL)