DDDS Service Coordinator Delaware Person Centered Plan

After DDDS clinical approval, your young adult is assigned a case manager. But which type of case manager they get — and what that person can actually do for you — depends on their current service status. The distinction between a Community Navigator and a Support Coordinator determines how much direct help you receive in accessing funded services.

Community Navigator vs. Support Coordinator

Community Navigator. Assigned to individuals who are DDDS-eligible but do not have active Lifespan Waiver services — typically young adults living at home with family. Community Navigators are contracted through the Columbus Organization, not employed directly by DDDS. Their role is to maintain contact, track the individual's status, connect the family with available non-waiver supports (respite, Pathways to Employment, DVR referrals), and update DDDS on any changes in the individual's living situation or support needs.

Community Navigators carry large caseloads and their level of proactive outreach varies. Families should not wait for the Navigator to call — initiate contact quarterly and document every conversation in writing (email is better than phone for creating a record).

Support Coordinator. Assigned to individuals who are actively enrolled in the Lifespan Waiver and receiving funded services. Support Coordinators are DDDS staff or contractors who manage the person-centered plan, coordinate between providers, and conduct annual plan reviews. Ask the Support Coordinator which service authorizations, provider changes, and priority questions they can handle or route through DDDS.

The appropriate contact depends on the individual's current living and service arrangement. A young adult living at home without active waiver services generally works with a Community Navigator; a Support Coordinator generally supports someone receiving waiver services in a provider-managed setting. Ask DDDS which contact is assigned if the arrangement is changing or services have not started.

The Person-Centered Plan

The person-centered plan (PCP) is the legally mandated document that drives everything — which services the individual receives, how many hours per week, which providers deliver them, and what personal goals guide the support. Every decision about the young adult's services flows from this document.

The plan is developed in a meeting facilitated by the case manager. Federal Medicaid rules require that the meeting be held in a setting chosen by the individual, that the individual's preferences remain central to all decisions, and that the plan reflects the person's goals rather than what is administratively convenient for the provider or agency.

What the PCP should include:

• Personal goals for housing, employment, education, relationships, and community participation
• Specific services authorized under the Lifespan Waiver (residential habilitation, day habilitation, supported employment, personal care, crisis stabilization, assistive technology)
• The number of authorized hours per week for each service
• The names of chosen provider agencies
• Medical needs, behavioral support requirements, and communication preferences
• Health and safety risk assessments

Making the Plan Work for You

The PCP is reviewed annually, but families can request a plan amendment at any time if the individual's needs change. Common triggers for an amendment include a change in living arrangement, a new medical diagnosis, loss of a caregiver, or a shift in employment or day program goals.

At each annual review, come prepared with specific requests. The case manager uses the PCP to justify service authorizations to DMMA and DDDS administration — vague language like "needs more support" gets less traction than "needs 15 hours/week of community habilitation to maintain competitive employment at [employer], currently authorized for 8 hours."

If you disagree with the case manager's recommendations or believe the plan does not reflect the individual's preferences, you can bring an advocate and ask the case manager how to request an amendment or appeal. The Community Legal Aid Society (CLASI) and the Parent Information Center (PIC) can both assist with PCP disputes.

County-Level Realities

Service delivery varies by county. New Castle County has the highest density of provider agencies and day programs, making it easier to get preferred providers and shorter wait times for service starts. Kent and Sussex counties have fewer providers and longer matching times, especially for specialized services like behavioral support or residential habilitation.

Your case manager — whether Navigator or Coordinator — should be transparent about provider availability in your county. If they are not, ask directly: "Which provider agencies currently have openings for [specific service] in [county]?" This forces a concrete answer rather than a general assurance.

The Delaware SSI at 18 & Adult Disability Benefits Guide includes a communication log template for tracking every interaction with your case manager and provider agencies, along with questions to ask at each quarterly check-in and annual PCP review.

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