Shawnie Rechtenbaugh, Department Secretary

long term services and supports (LTSS) home page
LTSS Forms & Publications
Home & Community-Based Services
Caregiver Supports
Nursing Facility Care
Provider Resources
Dakota At Home
Links and Resources
Ombudsman Program
Senior Health Information & Insurance Education (SHIINE)
Referral Form

long term services and supports

Case Management

Case Management Services assist individuals 60 and older and adults 18 and older who have a physical disability decide which available long-term services and supports can assist them to continue residing in their home and/or community.

The Long Term Services and Supports (LTSS) Specialist assists the individual to access long-term services and supports available through Long Term Services and Supports Programs and reviews program eligibility requirements. In addition, the LTSS Specialist is knowledgeable about other agencies that have programs and services that are available to meet the individual's needs.

Long Term Services and Supports Specialists' Role

The Long Term Services and Supports (LTSS) Specialist responds to inquiries or requests for service made by the individual or on the behalf of the individual. The LTSS Specialist provides assistance through the following functions:  Intake and Referral, Assessment, and Care Plan Development.

Intake and Referral

The LTSS Specialist responds to requests for information, assistance, and referral to available services and supports when an individual or family initiates a contact (e.g., email, fax, telephone, walk-in).  The LTSS Specialist assists the individual identify and determine the type of in-home services he/she may benefit from through LTSS Programs.  In addition, the LTSS Specialist can make a direct referral to assist the individual in accessing beneficial services and supports available through other agencies programs.  The LTSS Specialist gathers and reviews all relevant documentation and information obtained during the intake process to identify an individual's level of need for services and/or need for further assessment.


Based on the individual's level of service need, the LTSS Specialist may complete an in-home assessment.  The assessment focuses on the individual's function and quality of life and covers the following four areas:  Functional Performance, Cognition and Mental Health, Social Life, and Clinical Issues.  The individual's need for services and supports are identified and addressed through the development of a Care Plan.

Care Plan Development

The LTSS Specialist schedules a meeting with the individual in his/her home to develop a Care Plan.  Care Plan development is a collaborative process with the individual, family/friends and the LTSS Specialist.  Information gathered from the assessment helps identify the individual's strengths, preferences, and needs.  As needs are identified, the individual and/or a representative of the individual, indicate if and how each need can be addressed through services provided by LTSS, natural supports, and/or other services available in the community.

Goals and strategies are developed that include the services and supports which will assist the individual to continue residing in their home and/or community.  The LTSS Specialist discusses available options with the individual and his/her representatives for addressing unmet needs.  The LTSS Specialist reviews the type, scope, amount, duration, and frequency of services recommended and provides the individual with estimated cost (s) of each service contained in the Care Plan.  The LTSS Specialist is responsible for monitoring and revising the Care Plan when the individual's needs change.