Supporting Personal Independence: Inside the Work of LTSS Care Coordinators

The phrase “long term services and supports” or LTSS, refers to a wide range of health and personal care and support services. From meal preparation to accessible transportation, these supports can give people with disabilities or long-term illnesses more independence. And that independence leads to better health and well-being.

“When people are supported to be independent, they experience less depression and anxiety,” said Heather W., an LTSS service coordinator for the Elevance Health-affiliated Medicaid plan in Texas.

More than 3,000 care coordinators employed by Elevance Health-affiliated plans visit with members daily in their homes, in assisted living facilities, and in nursing homes with the goal of helping them live the lives they want. Elevance Health-affiliated plans in 2024 earned the Person-Centered Organization designation, which guides the company’s approach.

“It’s an honor,” said LTSS coordinator Ashley F. “Members open their doors and their lives to us. We meet grandkids, hear life stories, and work to help them make it another year in the home they love.”
 

Caring and Advocating

Most Elevance Health associates who work in these roles have experience as social workers or nurses and in supporting older adults or people with disabilities. They have worked as registered nurses in hospitals, as nursing facility coordinators, and for home health agencies. They lean heavily on skills such as strong verbal and nonverbal communication, compassion, coordination and organization, and relationship-building.

“Relationships can make or break you” when it comes to advocating for members and effectively working with nursing homes and assisted living facilities, said LTSS coordinator Kandise J. “When you work with nursing homes and assisted living facilities, relationships can make your life easier. Following up is important. Rapport is important.”

Helping members maintain their optimal level of independence and decision-making for themselves is also important, Ashley said. “It’s a privilege for someone to allow me to come into their home and into their lives,” she said. “To be able to help them safely stay where they want to be” and maintain their independence.

LTSS coordinators’ work can range from double-checking medications to confirm dosages, to small gestures like working with nursing home staff to make sure a member receives their favorite food with their breakfast each morning. “It’s easy for communication to get lost,” Kandise said. “We make sure to follow through because it’s meaningful and makes a difference in their day.”

For Edlyn E., a nursing facility LTSS care coordinator, it’s about ensuring the member is included in decision-making. “A lot of people don’t have anyone to advocate for them,” she said. “We develop care plans, help them relocate if they want, and connect them with in-network care providers. It’s about identifying resources—and safeguarding dignity.”

Nicole L., a field coordinator, often finds herself informing members about benefits they never knew existed. “Some families may need specific care and don’t know what’s available,” she said. One time Nicole worked with a woman with cerebral palsy whose aging parents lifted her into the tub daily—until she helped them secure home modifications. “Now, her parents don’t have to strain themselves and put their own health at risk, and she’s still able to live at home. That’s what people want.”
 

Taking Care of Others While They Also Take Care of Themselves

Previously, Ashley said, she worked in a hospital setting. “In the hospital, we don’t always know what happens when people leave,” she said. “Now, I get to go into homes, see how they’re really doing, and help them get what they need.”

As a former labor and delivery nurse, Heather said she now enjoys the opportunity to continue to care for children who may have been born with a disability. “It’s kind of a full circle moment for me,” Heather said. “One of my patients recently started wearing dentures, which helped tremendously with their nutrition and their self-confidence.”

“This role lets me prioritize my well-being,” Kandise said. She can use her nursing skills in a different way, and she can take better care of herself and spend time with her family. “Many times, nurses have jobs that don’t give them time with their families because they come home so exhausted. But this role has been rewarding on both ends.”

Ashley said the company encourages the team to take care of themselves. “They stand with us—they know we have to take care of ourselves in order to take care of others.”