Last updated April 24, 2024

 When to use: 

Listen for indicators of a good referral to resource coordinators:

• Needs in-depth support to return home from a facility or remain in their current community living setting
• Needs three or more types of referrals
• The call will take a long time or follow-up to research and go over resources
• Needs some additional help connecting with resources
• Complex needs (chronic conditions or co-morbidities)
• Overwhelmed client and/or caregiver
• In a nursing or assisted living facility or considering moving to one
• Difficulty hearing or vision loss
• Homeless or at serious risk of being homeless
• You believe they would benefit from ongoing support
• Expresses dementia or memory loss concerns, repetitive questions
• History of falls or high fall risk
• Needs home safety, modifications, repair and/or financial assistance to help modify home

Confirm if the person is on Medical Assistance by looking them up in MMIS. If they are on Medical Assistance, do not make the referral. 

 If the situation seems like a good referral: 

Talk about the support a resource coordinator can provide, including assessing their needs and coordinating a support plan. Do not promise in-person visits or a specific date the coordinator will follow-up.

Example referral language: 

Resource coordinators assist people looking to return to or remain at home through changes in their life. Resource coordinators will do an assessment to get to know more about you and your situation. They'll help identify supportive services, create a support plan and coordinate with caregivers when appropriate. They will also follow up by phone to make sure things are going well through the transition. Does this sound like something that would benefit you? 

If speaking with a caregiver, explain that we will need legal permission (verbal, ROI, POA) to work with the client. 

 If the person agrees to a referral: 

Assign a task to the Resource Coordination queue of the region the person is currently living in.  Be sure to include the person’s location, the situation, any programs they are on, and what you have done so far. The resource coordinator will call the person back and determine next steps. Again, do not promise in-person visits or a specific date the coordinator will follow-up.

Example task language:

Resource Coordination Follow-up: Person needs help remaining at home. Is 89, widow, lives in Rochester home, has no services but needs help with bathing, groceries, and cleaning. Has financial concerns, but not on programs. Became overwhelmed by all the information and is hard of hearing. Reviewed resource coordinator role. Call her home phone number. No resources mailed yet. You can close my case when finished.

Once the referral is made, the resource coordinator will call the person and determine if in-person assistance is needed.

Note: Every region must assign someone to monitor and pull tasks from their regional queues.

 Helpful links: 

Senior LinkAge Line contact center map