Families approved for Georgia’s Elderly and Disabled Waiver Program often describe the same moment of relief followed by the same moment of confusion. The relief comes with the approval letter. The confusion comes a few days later, when they realize they are now dealing with a state program, an assessment, a care plan, service limits, and at least one new professional whose title they have never encountered before: the care coordinator, or in some cases the case manager.
Understanding what this person does — and what they cannot do — is one of the most useful things a family can learn. Handled well, the relationship with a care coordinator determines how much support a loved one actually receives and how smoothly the program works year after year.
A Quick Refresher on EDWP
The Elderly and Disabled Waiver Program is a Georgia Medicaid home and community-based waiver. Its purpose is straightforward: to allow people who would otherwise qualify for nursing home placement to remain in their own homes and communities instead, with services paid for by Medicaid.
EDWP is administered through two components:
CCSP — the Community Care Services Program. CCSP delivers a package of social, health, and support services as an alternative to nursing facility placement, coordinated through Georgia’s Area Agencies on Aging network.
SOURCE — Services Options Using Resources in Community Environments. SOURCE serves elderly and physically disabled members who meet an intermediate nursing home level of care and links home and community-based services to a primary care case management model, with a stronger emphasis on medical oversight.
The two components cover overlapping services — personal support services, adult day health, emergency response systems, home-delivered meals, respite care, and more — but they route participants through different structures. Which one a person enrolls in depends on their circumstances, including their Medicaid eligibility category and what is available in their county.
In both, a coordinating professional sits at the center of the arrangement. In CCSP, that person is generally called a care coordinator. In SOURCE, the equivalent role is usually called a case manager. Their day-to-day functions are close enough that families can think of them as the same job with different titles.
What a Care Coordinator Actually Does
1. Assessment and level of care
Before services begin, someone must establish that the applicant genuinely needs the level of care a nursing home would provide. The care coordinator conducts or arranges a comprehensive in-home assessment covering functional ability — bathing, dressing, toileting, transfers, mobility, eating — along with medical conditions, medications, cognition, home safety, and the informal support already provided by family and neighbors. Physician documentation supporting the need for intermediate nursing home care is part of this determination.
This assessment is not a formality. It sets the level of service authorized. Families sometimes minimize difficulties out of pride during the visit and then find the approved hours insufficient. Accuracy serves everyone better than optimism.
2. Building the plan of care
From the assessment, the care coordinator develops a person-centered plan of care: which services are authorized, how many hours or units, how frequently, and toward what goals. A plan might combine personal support services several days a week with an emergency response system, home-delivered meals, and periodic in-home respite so a spouse can rest.
“Person-centered” is meant literally. The plan should reflect the participant’s own priorities and preferences, not just a clinical inventory of deficits. If getting to church on Sunday or continuing to cook is what matters most to the participant, that belongs in the conversation.
3. Authorizing services and connecting providers
The care coordinator authorizes services and helps the participant select from enrolled providers in their area. Participants generally have the right to choose their provider agency, and it is worth exercising that right — ask about staffing reliability, training, supervision, and whether the agency can also deliver skilled nursing if needs increase.
Once a provider such as Hope Private Care is selected, the coordinator communicates the authorized services and the plan of care to the agency, which then staffs the case and begins service.
4. Ongoing monitoring
The coordinator’s job does not end when services start. They check in on whether services are actually being delivered as authorized, whether the participant’s condition is stable, whether the family is coping, and whether the plan still fits. Monitoring occurs through periodic contacts and home visits, with the frequency set by program requirements and the participant’s needs.
Provider agencies play a significant part here. Caregivers in the home see change first — a new wound, worsening confusion, weight loss, increasing falls, a family caregiver approaching collapse. Reporting those observations to the care coordinator promptly is what allows the plan to be adjusted before a crisis occurs.
5. Reassessment and plan revision
Participants are reassessed on a regular schedule, typically at least annually, and additionally whenever there is a significant change in condition — a hospitalization, a new diagnosis, a fall, the death or illness of a family caregiver. Reassessment can increase authorized services, change the mix of services, or, if needs have lessened, reduce them.
Do not wait for the annual review if something has changed. A request for reassessment can be made at any time, and it is the single most effective step a family can take when the current plan is no longer enough.
6. Advocacy, problem-solving, and transitions
Care coordinators also serve as navigators. They help resolve service gaps, address problems with a provider, connect participants to resources outside the waiver — durable medical equipment, transportation, food assistance, caregiver support programs — and manage transitions such as hospital or rehabilitation discharge back to home. If eligibility, service denials, or appeals become an issue, the coordinator explains the process and the participant’s rights.
What a Care Coordinator Is Not
Clarity here prevents frustration. A care coordinator is not the hands-on caregiver; they do not bathe, cook, or provide nursing care. They are not the participant’s physician and do not prescribe. They cannot authorize services beyond what the program covers or beyond what the assessment supports. And they typically manage a substantial caseload, which means they cannot be reached instantly at all hours.
The practical implication is that the provider agency and the family carry much of the day-to-day communication, while the coordinator manages the program-level decisions.
How to Work Well With Your Care Coordinator
A few habits make a large difference:
Prepare for the assessment. Describe the worst days, not the best ones. Keep a simple log of falls, missed medications, sleepless nights, and tasks the participant can no longer manage alone.
Keep one designated family contact. Multiple relatives calling with different information slows everything down.
Report changes in writing. A short email creates a record and is easier to act on than a voicemail.
Ask questions directly. How many hours were authorized and why? What would justify more? When is the next reassessment? What is the appeal process if a service is denied?
Choose a provider that communicates. A good agency documents carefully, flags changes early, and keeps the coordinator informed without being chased.
Hope Private Care Works With Your Care Coordinator
Hope Private Care is a licensed Georgia home care provider serving Metro Atlanta and the surrounding counties from our office in Snellville. We deliver personal support services, companion care, skilled nursing, and live-in care to participants in EDWP through both CCSP and SOURCE, working directly with state-appointed case managers and care coordinators to deliver exactly what the approved plan of care calls for — and to report promptly when a participant’s needs change.
If your family is enrolled in EDWP, awaiting approval, or simply trying to understand the process, call us at (770) 864-9398 or email info@hopeprivatecare.com. We offer a complimentary in-home assessment and can walk you through what to expect next.