Dementia navigation referral · Metropolitan Area Agency on Aging

Enrollment

For MAAA staff:

If enrolling: Use the link below to create a person record and enrollment pre-filled with the collected referral data. This referral will be automatically linked to the enrollment. When finished, set the referral status to Completed and select Eligible: Enrollment created as the closure reason.

Enroll in dementia navigation

This link will automatically search Cumulus for a matching person. If one is not found, the a new person can be created, pre-filled with demographics, with an enrollment created as well. CTRL+Click on link to open link in a new tab and keep this referral open.

Details

Full name of person being referred: Unanswered
Date of birth of person being referred: Unanswered
Phone number of person being referred: Unanswered
Email of person being referred: Unanswered
Address of person being referred: Unanswered
Primary language is English: Unanswered
Person's primary language: Unanswered

If not enrolling: Set the referral status to Completed and select the appropriate closure reason.

Referral creation source Calculated

Unanswered

Describe the other referral channel source

Has the CTN notified the referral source of the Client enrollment?

Select only one

Yes No

Referral source notification comments

Closure details

Referral closure reason

Select only one

Eligible: Enrollment created Eligible: Enrollment not created Ineligible Invalid referral submission Not enough information, submitted in error, etc.

Making a referral

Whether you’re a healthcare professional, community organization, family member, or friend, making a referral—or self-referral—is easy. Complete the form below, and a Care Ecosystem representative will follow up within 2 business days to conduct a brief assessment and help you determine the right level of support.

Program eligibility

The Care Ecosystem program of MAAA requires specific eligibility criteria. Please confirm the person you are referring meets all three of the following requirements:

1. Is the primary caregiver (18+) for a person living with dementia OR is a person living alone with dementia. No formal diagnosis required.

2. Lives in the Twin Cities seven-county metro community (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, or Washington county). The program is unable to accommodate those living outside the Twin Cities metro area at this time.

3. Resides in a home setting (private residence). The program is unable to accommodate those living in residential care or nursing care environments at this time.

Does the person meet all 3 requirements of the Care Ecosystem dementia support program?

Select only one

Yes No

Thank you for your interest in the Care Ecosystem dementia support program at MAAA. Unfortunately, your referral does not meet the current eligibility requirements of this specific program. MAAA offers additional free support services through Minnesota Aging Pathways including caregiver support, Medicare counseling, long-term care counseling and resource navigation. Minnesota Aging Pathways specialists can be reached at 1-800-333-2433, Monday – Friday from 8:00am to 4:30pm.

Information of person being referred

Person being referred

Select only one

Caregiver (age 18+) for a person with dementia A person living with dementia or experiencing signs of dementia

Full name

Date of birth

Phone number

Address

Start typing the address to auto-populate

Is the person's primary language English?

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Yes No Unknown

Other primary language

Does the person need language interpretation services?

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Yes No Unknown

Please note: this free phone-based service uses a third-party professional interpretation provider.

Is there a preferred time to contact this person?

Select only one

Morning Afternoon Unsure

Information of person filling out referral

If CTN is filling out form manually, enter information of the referral source contact here

Full name

Phone number

Relationship to person being referred

Describe the other relationship to the person being referred

Provide details about the family relationship

Title within the organization

Healthcare hospital

Other Healthcare hospital

Healthcare clinic

Other Healthcare clinic

Healthcare organization name

How did you hear about the Care Ecosystem program from MAAA?

Additional details

Any other information you'd like to share?

By submitting this form, you confirm that the person being referred (yourself or someone else) has given consent to share their information and understands that Metropolitan Area Agency on Aging Care Ecosystem will contact them to offer support or services pending eligibility review.

Dementia navigation referral - Metropolitan Area Agency on Aging website referral submissionsMetropolitan Area Agency on Aging website referral submissions

Enrollment

Closure details

Making a referral

Program eligibility

Information of person being referred

Information of person filling out referral

Additional details

Dementia navigation referral - Metropolitan Area Agency on Aging website referral submissions
Metropolitan Area Agency on Aging website referral submissions