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Sonoma County’s Adult & Aging Division offers case management programs to support the unique needs of older adults (60+) and people with disabilities of all ages. Each program has separate eligibility criteria and the length of involvement in the individual’s life varies. All programs offer support from an Adult & Aging Social Worker and Public Health Nurse to help qualifying Sonoma County residents live as safely and independently as possible in the community.

Upon completing the referral below, the information will be reviewed and screened by a social worker and program supervisor for two case management programs: Multipurpose Senior Service Program (MSSP) and Linkages Care Management. Both programs require that the referred individual, or designated support person be able to actively work with the program and oversee their own day-to-day needs. If the individual’s needs cannot be met by one of these two programs, the referred individual may be offered alternative community resources that could support them in other ways.

Linkages Care Management Eligibility Criteria
  • Age 60+
  • Age 18-59 (must have a disability; medical condition impacting ability to live safely in the community)
  • There are no income restrictions
  • Must be a Sonoma County resident
  • Willingness and Interest to engage with a social worker
Multipurpose Senior Service Program (MSSP) Eligibility Criteria
  • Age 65+
  • Active “full scope” Medi-cal
  • Current or anticipated resource needs (e.g. fall prevention, medical advocacy, incontinence supplies, Advanced Care planning, etc.) to reduce the risk of out-of-home placement
  • Requires assistance with routine tasks like dressing, mobility, toileting, or feeding, or has progressive illness (e.g., dementia or Parkinson’s Disease)
  • Must be a Sonoma County resident
  • Willingness and Interest to engage with a social worker
Referring Party Information
Prospective Client Information
Participation Readiness Assessment

The client is able and willing to help identify their own needs and participate in care planning.

The client has a committed support person to participate and follow up with care planning and steps to meet their goals.

Informal Supports

Needs Assessment