Develop a Personalized Plan of Care

Medicaid Plans of Care for In-Home Support

What Is a Plan of Care?

A Plan of Care is a personalized roadmap outlining the Medicaid-funded in-home care services your loved one may receive. This plan is developed around their:

Medical needs

Daily care requirements

Functional abilities

Level of independence

Home environment

Personal routines and preferences

This plan helps identify the types of assistance that may be authorized through Montana Medicaid programs, such as SD-CFC/PAS.

At Alpenglow Homecare of Montana, every Plan of Care is created in collaboration with the State nurse and can incorporate recommendations from your loved one’s physician to help support their broader medical care.

Personalized Care Planning for Medically Fragile Individuals

Caring for a medically fragile loved one often involves more than basic daily support. Many families are also trying to coordinate:

Medicaid requirements
Physician recommendations
Caregiving responsibilities
Long-term care planning

Our team helps simplify this process by guiding families through care planning, Medicaid coordination, and ongoing support requirements. We understand that no two families face the exact same challenges. That is why our approach focuses on personalized support instead of standardized care models.

How We Help Develop The Plan of Care

We understand that navigating Medicaid care planning can feel overwhelming, especially while caring for a loved one at home. Our team helps simplify the process by guiding families through assessments, documentation, and ongoing care planning requirements.

Initial Phone Consultation

The process begins with a phone consultation with our team. During this conversation, we gather information about your loved one’s condition, current caregiving situation, daily support needs, and potential Medicaid eligibility considerations.

We also answer questions about the care planning process and explain what families can expect moving forward.

Working Together With Families & Caregivers

Family caregivers play an important role in developing an effective Plan of Care. At Alpenglow Homecare of Montana, we work closely with:

Family members

Primary caregivers

Healthcare providers

State nurses involved in the assessment process

Your firsthand knowledge helps us better understand your loved one’s routines, preferences, daily challenges, and support needs.

State Nurse Assessment

For a Plan of Care to activate, a State-appointed Registered Nurse (RN) must complete a formal assessment. 

During the visit, the state nurse evaluates the individual’s care needs and determines what support may qualify under the program. Depending on the situation, this assessment may take place in the home or over the phone.

Our team helps families prepare for this process so they better understand what information may be discussed during the evaluation.

Free In-Home Consultation

Once the assessment and approval process moves forward, we begin organizing the individualized Plan of Care with your family. Our local care coordinators visit your home in Missoula, Great Falls, or surrounding areas and work directly with families to develop the Plan of Care in greater detail.

During this visit, we may review:

Medical Needs

Review of medical history, diagnoses, and ongoing health concerns, to ensure care aligns with clinical goals.

Activities of Daily Living (ADLs)

Assessment of necessary support with bathing, dressing, eating, toileting, transferring, and other daily activities.

Functional Abilities

Evaluation of mobility, physical strength, current level of independence, and safety within the home.

Daily Preferences & Routines

Valuable inputs regarding personal habits, schedules, and caregiving preferences that help improve comfort and consistency.

Adjusting the Plan as Needs Change

We understand that care needs can change over time, especially for medically fragile individuals or those managing progressive conditions. 

That is why Alpenglow Homecare of Montana regularly reviews and adjusts Plans of Care when needed. We help ensure services continue to match the patient’s:

Current condition
Support needs
Daily challenges
Health status

We help families understand when reassessments may be needed and assist with ongoing coordination related to care planning requirements.

What Kind of Support is Included in a Plan of Care?

The services included in a Plan of Care depend on the individual’s assessment, Medicaid authorization, and program guidelines. A personalized plan may include support related to the following areas.

ADLs or Personal Care Assistance

The plan will outline the daily activities that your family member may need. This can include bathing, dressing, toileting, transferring, and more.

Meal Preparation Support

Support with grocery planning, meal preparation, and maintaining dietary needs while helping loved ones eat safely and comfortably.

Transportation Support for Medical Appointments

For qualifying individuals, transportation support may be authorized for:

  • Doctor appointments
  • Medical visits
  • Essential healthcare-related travel

This can help reduce logistical stress for caregivers and families.

Housekeeping & Laundry Assistance

Based on patient needs and authorization, additional support services may include light housekeeping, laundry assistance, and home organization support. These services can help caregivers focus more attention on their loved one’s care and well-being.

Why Individualized Care Planning Matters

A well-developed Plan of Care can help families:

Better organize caregiving responsibilities
Understand available support options
Create clearer expectations for day-to-day care at home
Navigate Medicaid requirements with less confusion
Adjust care plans as needs change over time

For many caregivers, having a structured plan also provides a clearer understanding of what types of assistance may be available based on the individual’s medical, functional, and daily support needs.

Helping Families Navigate Medicaid-Funded In-Home Care

We help families understand available Medicaid-supported care options and develop care plans that reflect real day-to-day needs at home.

We help families understand:

Available in-home care benefits

SD-CFC/PAS program guidelines

Medicaid documentation requirements

Eligibility considerations

Authorized support services

Ongoing care coordination requirements

Our goal is to help families access the maximum level of support available for their loved one’s situation.

Talk With Our Team About Your Family’s Needs

We are committed to providing compassionate, personalized support to your family, allowing your loved one to maintain independence and dignity at home. We can answer your questions about the care planning process, the SD-CFC/PAS program, and your Medicaid documentation.

Schedule your free initial consultation today. To contact our office in Missoula, MT, please call 406-501-4491 or fill out our online form.

712 W Spruce St, Suite 101
Missoula, MT 59802

721 Central Ave
Great Falls, MT 59401

2345 King Ave W, Ste A
Billings, MT 59102

Monday - Friday
9:00 AM - 5:00 PM

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