Understanding Support Coordination in Georgia's Waiver Programs

When a Georgia Medicaid waiver finally comes through, most families expect the hard part to be over. Then the paperwork arrives, and with it a name they have never heard before: a support coordinator, a care coordinator, a case manager. Someone who is supposed to help, but whose job nobody has explained.

That person can be the single most useful ally in your loved one's care. Or, if you do not know what to ask of them, they can become just another name on a form. This guide explains what support coordination is, how it works in each of Georgia's major waiver programs, and how to make the relationship work for your family.

What a Support Coordinator Actually Does

Every Georgia home and community-based waiver includes some form of coordination. The titles vary by program, but the core responsibilities are the same:

• Assessment. Learning what the person needs, what they want, and what is already in place.
• Planning. Leading the meeting where the service plan is written, with the participant and family in the room.
• Authorization. Approving the specific services, hours, and providers the plan calls for.
• Monitoring. Checking in regularly to confirm services are actually being delivered and are still the right fit.
• Connection. Linking the family to supports outside the waiver, such as SSI, school services, transportation, or vocational rehabilitation.

Under federal rules, this coordination must be conflict-free. That means the person who writes and monitors your plan cannot work for the agency that delivers your services. Their loyalty is supposed to be to the participant, not to a provider.

Think of the coordinator as the one person in the system whose job is to look at the whole picture. Nurses, aides, and day programs each see their piece. The coordinator is meant to see all of it.

Support Coordination in the NOW and COMP Waivers

For people with intellectual and developmental disabilities, the NOW and COMP waivers are administered by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). When a slot opens, DBHDD assigns a Support Coordinator from an independent, DBHDD-contracted agency. Roughly 12,000 Georgians in NOW and COMP receive this service.

The Individual Service Plan (ISP)

The centerpiece of NOW/COMP support coordination is the Individual Service Plan, or ISP. The support coordinator facilitates the ISP meeting, writes the plan, and updates it at least once a year. The ISP is where hours are set, providers are named, and goals are recorded. If something in your loved one's life has changed, the ISP is where that change has to show up.

What to Expect

• Support coordinators carry caseloads of 40 or fewer participants.
• Visits happen at least quarterly, and monthly for participants whose ISP calls for closer follow-up.
• Each quarterly visit includes a face-to-face quality outcome review, checking health, safety, and whether services are working.
• The coordinator can help with community living supports, supported employment, respite, and residential options, and can connect the family to non-waiver resources.

Intensive Support Coordination

Participants with the highest risk status, including exceptional medical or behavioral needs, may be assigned Intensive Support Coordination (ISC). ISC coordinators have caseloads of no more than 20, make at least one face-to-face home visit every month, and work under a clinical supervisor who is a registered nurse or licensed behavioral professional. About 1,900 Georgians currently receive ISC. If your loved one has frequent hospitalizations, complex medications, or behavioral crises, ask your DBHDD regional field office whether ISC is appropriate.

Still on the Planning List?

If your family is waiting for a NOW or COMP slot, you are not entirely without support. Georgia offers targeted case management for people on the planning list, which provides some of the same planning and connection functions while you wait. Ask your regional field office about it, and report any significant change in circumstances, since DBHDD reassesses urgency when needs change.

Care Coordination in CCSP and SOURCE

The Elderly and Disabled Waiver Program (EDWP) serves older adults and adults with disabilities who meet a nursing-facility level of care but want to stay home. It is delivered through two programs, and the coordination role is central to both.

CCSP: Community Care Services Program

In CCSP, a care coordinator (often a nurse or social worker) completes the assessment, writes the care plan, and authorizes services such as personal support, adult day health, home-delivered meals, emergency response systems, and skilled nursing. Contact is typically monthly, with in-home visits at least quarterly and a full reassessment every year. The care coordinator works alongside the member's own primary care doctor.

SOURCE: Service Options Using Resources in a Community Environment

SOURCE looks similar on the surface, but it is built around enhanced primary care case management. Every SOURCE member has a dedicated primary care physician within the SOURCE network, and the case manager works directly with that doctor to coordinate medical care and home services in a single plan. The case manager conducts the initial assessment, authorizes services, visits at least quarterly, and responds when something goes wrong, including critical incidents.

For families, the practical difference is that a SOURCE case manager is closely tied to the medical side of care. If your loved one has several chronic conditions and sees multiple specialists, that integration can be a real advantage.

Case Management in ICWP

The Independent Care Waiver Program (ICWP) serves adults ages 21 to 64 with severe physical disabilities or traumatic brain injury. Here the coordinator is usually called a case manager and works for a DCH-contracted case management agency.

ICWP places a strong emphasis on member direction. The case manager verifies eligibility and level of care, develops the person-centered plan with significant input from the participant, authorizes services, and monitors safety and delivery. For members who choose to self-direct, the case manager also helps them work with the financial management services agency and understand their responsibilities as employer of record.

If independence is the goal, the ICWP case manager is the person who helps make it concrete: personal support hours, skilled nursing, home modifications, and the equipment that ties them together.

What About GAPP?

The Georgia Pediatric Program (GAPP) works differently. It is a service delivery program for medically fragile children under 21, not a case management program. There is no separately assigned support coordinator. Instead, coordination happens through the nursing team at the enrolled GAPP provider agency, working with the child's physicians and, often, the care coordinator at the child's Medicaid managed care plan.

For GAPP families, that makes the choice of provider agency especially important. The agency's clinical team is effectively your coordination team.

How to Get the Most From Your Coordinator

A coordinator can only act on what they know. Families who get the most out of the role tend to do a few things consistently.

• Prepare for the planning meeting. Write down what is working, what is not, and what has changed since last year. Bring recent medical notes and any new diagnoses.
• Ask for the plan in writing. You should have a copy of the ISP or care plan. Read it. If the hours or services listed do not match what is actually happening, say so.
• Report changes promptly. A hospitalization, a new diagnosis, a caregiver who moves away, a change in behavior: each of these can justify a plan revision, but only if the coordinator hears about it.
• Keep a simple log. Dates of visits, calls made, questions asked, promises given. It makes every conversation shorter and more productive.
• Know your rights. You can request a plan review at any time, not just annually. You can also request a different coordinator if the relationship is not working. For NOW/COMP, that request goes through your DBHDD regional field office. For CCSP, SOURCE, and ICWP, contact the case management agency or the Department of Community Health.

If you have not heard from your coordinator in more than a quarter, that is worth a phone call. Regular contact is not a courtesy. It is a program requirement.

Coordinators and Providers Working Together

The coordinator writes the plan. Providers like Heart and Soul Healthcare carry it out. The best outcomes come when those two sides talk to each other, and families are the bridge.

When a provider notices something the plan does not cover, whether that is a need for more hours, a new piece of equipment, or a change in a client's condition, the right move is to document it and bring it to the coordinator. A good home health agency does this as a matter of course, and a good coordinator welcomes it.

If you are just starting the waiver process, or you have a plan in place but are not sure it reflects your loved one's real needs, we can help you understand what your coordinator can authorize and how to ask for it.