Care Management and Personal Support
Care Management and Personal Support
When several challenges happen at once, it can be difficult to know where to begin. SFF care managers work with individuals and families to understand their needs, organize priorities, connect with appropriate programs, and follow through on referrals.
Care management provides ongoing, person-centered assistance for individuals and families navigating multiple health, housing, financial, employment, or social-service needs. The care manager helps develop a plan, coordinates referrals, assists with documents and applications, and follows up on progress.
What a Care Manager Can Do
Complete a comprehensive intake
Identify immediate and long-term needs
Develop a personalized support plan
Help prioritize urgent concerns
Assist with applications and documentation
Coordinate referrals among different organizations
Communicate with providers when authorized
Track referral progress
Help address barriers to receiving services
Follow up with the member
Connect the member with long-term community resources
Areas of Support
Housing and Utilities
Housing resources, rental-support referrals, eviction-prevention resources, utility programs, and documentation assistance.
Food and Nutrition
Food assistance, nutrition programs, food resources, and qualifying Social Care Network referrals.
Healthcare and Insurance
Health insurance navigation, primary-care referrals, specialist referrals, and assistance understanding available options.
Behavioral Health
Connections to appropriate mental-health, substance-use, or community-based providers.
Employment and Education
Employment planning, résumés, interview preparation, vocational programs, educational resources, and ESL referrals.
Benefits and Financial Stability
Public-benefit applications, budgeting education, financial-literacy support, and connections to legal or financial resources when appropriate.
Family and Community Support
Connections to childcare, disability services, youth resources, older-adult services, and community programs.
Care Management Process
01
Intake
The member explains their concerns and priorities.
02
Assessment
SFF identifies needs, strengths, existing supports, and urgent concerns.
03
Personal Support Plan
The member and care manager establish goals and next steps.
04
Referrals and Applications
SFF helps connect the member with appropriate resources.
05
Coordination
The care manager helps organize communication across involved providers when authorized.
06
Follow-Up
Progress is reviewed and the support plan is updated as needed.