Interpretation: While the decision to develop an aftercare plan is based on the wishes of the service recipient, unless aftercare is mandated, the agency is expected to be strongly proactive with respect to aftercare planning.

PA-HCS 8.01

The aftercare plan is developed sufficiently in advance of case closing to ensure an orderly transition.

PA-HCS 8.02

The aftercare plan identifies services needed or desired by the person and specifies steps for obtaining these services.

PA-HCS 8.03

The agency takes the initiative to explore suitable resources and contact service providers when appropriate, with the permission of the person, family or legal guardian.

PA-HCS 8.04

The agency follows up on the aftercare plan, as appropriate, when possible, and with the permission of the service recipient.

Interpretation: Reasons why follow-up may not be appropriate include, and are not limited to, cases where the person’s participation is involuntary.

PA-HCS 8.05

The agency:

conducts a formal final evaluation and assessment of unmet needs; and
informs other relevant public entities of the findings, in writing, as appropriate, and with the permission of the family.

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	PURPOSE: Individuals who receive Home Care and Support Services obtain a maximum level of independence, functioning, and health, and extend the time it is possible to live safely at home and in the community.

RELATED FILES

PA_HCS Template.doc
NA Request.doc
PA-HCS Reference List.pdf


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	AFTERCARE Additional services provided beyond the period of primary care that offer continuity and supportive follow-up.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	CASE CLOSING A voluntary or involuntary process which occurs when an organization no longer assumes responsibility for providing services to a particular individual, group, or family. Also known as "termination" or "discharge."


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	EVALUATION The review and assessment of organizational operations, programs and services.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.