The process begins with an initial pre-admission assessment for each veteran referral. The veteran’s needs are identified and measurable goal and outcomes are established. The Case Manager will determine what issues must be addressed first.  The Case Manager will ensure that a referral is made to partners in the community for needs that require specialized treatment, support or services.  Follow-up is monumental.  The Case Manager will follow-up until successful linkage has been established.  Once linkage has been established the Case Manager will continue to function as an advocate for the Veteran actively networking on behalf of the Veteran. The Case Manager will ensure that there is no duplication of services and assist with removing any barriers which might impede the success of the Veteran.

The next step encompasses developing a Personal Development Strategy (PDS). The PDS is a “living document” developed with the input from the veteran, the veteran’s family members, and professionals. The team’s input will be critical to ensure the effectiveness of PDS and to establish a good benchmark in order to gauge each veteran’s progress. The PDS will also be utilized to continually evaluate the veteran’s progress. The goal is to track the progress of each veteran and to adapt a plan of action as needed. The plan will also include the individual’s needs to specify which agency will be responsible for meeting medical needs, particularly in the event of crisis.  To foster an environment where Veterans feel safe and a part of; opportunities will exist for both individual and group activities on-site and in the community.

The goal is to increase the independence of veterans. The staff will instruct and assist with daily living and self-care skills, providing prompting in lieu of direct assistance.  Daily living skills include monitoring and assistance with meal preparation, laundry, housecleaning, home maintenance, money management, and appropriate social interactions. Self-care skill includes bathing, dressing, toileting, eating, and taking prescribed medications.

​Staff will also assure that residents receive necessary services from community service providers including medical care, physical therapy, occupational therapy, vocational training, education and mental health services.