1. RCAW Caregiver Respite Grant Program

2. RCAW’s Caregiver Respite Grant Program funds are from a grant from Wisconsin Department of Health Services - Division of Medicaid Services.

3. First Step!
Prior to completing an application, please review the following before proceeding further:
Have you or the care recipient applied for long term care (LTC) supports?
__ If yes but are waiting to learn if you are approved LTC services, AND respite need is an emergency, you can move forward with the application. Note: You will need to provide ADRC or County Contact Information for confirmation. If respite is not an emergency, you are not eligible to apply.
__ If yes but were denied LTC services, you can move forward with the application, however a copy of the denial letter MUST accompany your application. NO EXCEPTIONS!
__ If you have not applied for LTC, you need to start there first!
Click here to find your local ADRC for adult LTC programs and supports
Click here to find your local County contact for children LTC programs and supports

4. About the Program.
This is a grant program where respite services must be rendered during a specified pre- determined time period.
Respite grants are available to unpaid family caregivers across the lifespan – meaning you can be providing care for a child or an adult.
There is no minimum or maximum amount of assistance. Each request will be reviewed on its own merit, given the needs of the care recipient, respite options available, length of time, etc. Please be reasonable with your request.
This round of funding is available until June 30, 2019 as they are subject to renewal by WI DHS annually.
Respite grant assistance can only be requested a maximum of 4 times per year.

5. Who’s Eligible?
Primary family caregiver who is unpaid for their caregiving duties and who is age eighteen (18) or older
Live in the State of Wisconsin; but does not have to live with the care recipient
Caring for care recipient who is not eligible for Medicaid or other program(s) that provides respite services;
Exceptions may be made for emergency respite needs at the discretion of RCAW.

6. Important!
Incomplete applications will not be considered and be returned (unless eligibility has already been determined via a prior submission).
Traditional respite funding resources will be the first source for those needing respite. RCAW respite assistance will not supplant other respite funding sources.
Caregiver’s who are found to be mis-using respite grant funds will be forbidden from the program in perpetuity.

7. The Application Form

8. RCAW Caregiver Respite Grant Program Application
Caregivers of individuals, who need support with personal care, supervision, and monitoring, may find themselves in need of respite (short breaks) from their caregiving responsibilities. The purpose of this Caregiver Respite Grant Program is to meet planned respite needs for unpaid caregivers. Lifespan Respite is based on individuals who have a special need or needs.
Eligibility Criteria
In order to qualify for this program, THE ELIGIBLE CAREGIVER MUST MEET ALL OF THE FOLLOWING:
Be the primary family caregiver of a family member
with a “Special Need”;
Live in the State of Wisconsin;
Not be enrolled in a Medicaid or other
program* that provides respite services;
May receive respite grant if on a
wait list and not scheduled to receive
services within thirty (30) days of application;
and
Caregivers do not have to live with the care recipient.
Additionally, the eligible care recipient must meet one of the following set of criteria: The Lifespan Respite Act of 2006 describes “special need” as, check one:
An adult, 18 years of age or older who requires care or supervision to include:
1. Meet the person’s basic needs;
2. Prevent physical self-injury or injury to others; or
3. Avoid placement in an out-of- home, long-term care setting.
A child, less than 18 years of age who requires care or supervision beyond that required of children generally to:
1. Meet the child’s basic needs; or
2. Prevent physical self-injury, or injury to others.

9. Eligibility Criteria (cont.)
*Is the care recipient enrolled in, or on the wait list for, check one:
Family Care
I.R.I.S. (Include, Respect, I Self-Direct)
Children’s Long-Term Care Support (CLTS)
Children's Community Options Program (CCOP) 
National Family Caregiver Support Program (NFCSP)
Alzheimer’s Family Caregiver Support Program (AFCSP)
Foster Care Support Services
Deemed not eligible for any of the above programs
Note: If you have not heard or inquired about any of these programs, please contact:
your local ADRC for adults,
your county contact for children

10. Important information about the RCAW Caregiver Respite Grant Program:
Planned Respite: if you are or have been approved for respite reimbursement from RCAW, you can’t receive funding for 90 days after respite services were performed, unless its an emergency. Assistance will only be provided up to 4 times per year.
Respite grants requests are typically filled on a first-come, first-served basis. However, some applications may not be awarded due to extenuating circumstances.
Emergency Respite: Emergency needs will be assessed as they come in at the discretion of RCAW staff.
There is no minimum or maximum amount of awarded. Each reimbursement request is reviewed on a first come first serve basis along with maintaining equitable distribution of respite reimbursement requests geographically.
Respite grant requests will be based on actual hours requested at pre-approved rate. The number of hours provided cannot exceed the amount approved but can be less. Or caregiver can pay the difference.
Caregivers are responsible for respite scheduling, supervision, and reviewing the credentials and safety training of respite providers. These caregivers are encouraged to consider the kinds of help they or their care recipient are looking for in a respite provider.

11. Servicing All of Wisconsin
Important information about the RCAW Caregiver Respite Grant Program: cont’d.
The following questions may be helpful when reviewing respite options:
What sort of help does the caregiver or care receiver need?
How much time will the respite worker be providing care per session? (Hint: It is easier to find in-home workers if they are scheduled for four-to-eight-hour blocks of time.)
What are the basic qualifications a respite care provider must have in order to safely provide care?
Are there special skills required to work with the care receiver?
Ask if the respite care worker has a recent copy of a criminal and caregiver background check they can provide you, or ask how the agency verifies respite care worker’s caregiver and criminal background history?
For additional information on how to interview paid workers, please refer to our free on-line training course called
‘How to Hire a Respite Care Provider’
Submit completed application to: RCAW Lifespan Respite Reimbursement Program via at of fax at
Servicing All of Wisconsin

12. Caregiver Information
Caregiver Name: __________________________________________________________________
Address: ____________________________ City: State: WI Zip:
County: _____________________________ Phone: ( )
Gender/Sex: Male Female Other D.O.B.: Age:
Relationship to Care Recipient: Parent/Step Parent Foster Parent
Guardian Other Relative, Please specify:
Race: African American Asian American Caucasian Native American
Other, Please specify:

13. Eligibility and Need
I am the primary family caregiver of the care recipient Yes No
I receive respite care through Medicaid or other programs that provide respite care Yes No
If Yes, Please provide Program Name:
I have received RCAW Caregiver Respite Grant Program funds in the past ninety (90) days Yes No
How long have you been an unpaid family caregiver? < 6 mos. > 6 mos. < 1 Yr. 1 – 5 Yrs. 5+ Yrs.
How long since you last had a break from caregiving? < 6 mos. > 6 mos. < 1 Yr. 1 – 5 Yrs. 5+ Yrs.
What has kept you from having breaks in the past? Money Timing Available Provider Transportation
Other:
What type pf respite support is needed? In-Home Out of Home Overnight Care Weekend Care Camp
Unsure Other:
8. Is this Emergency respite care; OR Routine/planned respite care: (Check one)
Explain:

14. Care Recipient Information
(Fill out separate application for each person needing care or supervision)
Care Recipient(s) Name:
Address: City: State: WI Zip:
County: _________ _____________________________ Phone: ( )
Gender/Sex: Male Female Other D.O.B.: Age:
Special Need or Condition (person needing care): Brain Injury Emotional/Behavioral Neurological
Intellectual/Developmental Disability (IDD) Mental Health Disorder Physical
Medical Supports Needed Special considerations needed (Behavior/Lift, etc.) Memory Condition
Other considerations:
Amount of care the family caregiver provides: hours per day
days per week

15. Respite Care Worker or Provider/Agency Information
Respite Care Worker or Provider Name:
Respite Care Provider/Agency (if applicable):
Contact Title and/or Relationship:
Street Address or P.O. Box:
City: State: WI Zip:
Primary Phone # ( )
Will respite be provided in-home; at a facility; or at a camp? (Check only one)
Has the respite care worker taken and passed RCAW’s free on-line core curriculum training? Yes No
Is the respite care worker listed on RCAW’s free on-line respite care provider registry? Yes No

16. Respite Services Information
(Fill out separate application for each person needing care or supervision)
Date(s) of care to be provided: From To
And/or projected hours:
Estimated cost per day: Number of days:
Amount Requested: $
The Respite Service Provider/Worker was selected because: familiarity with care recipient only option available
convenient location liked the facility could provide in-home respite other:___________________
If application is approved, RCAW will notify the applicant of the Caregiver Respite Grant Program award and care giver/applicant can proceed with approved respite.
Date
Family Caregiver’s Signature
Family Caregiver’s Printed Name

17. Incomplete applications will not be considered and will be returned.
Submit the completed RCAW Caregiver Respite Grant Program Application to:
Attention: Caregiver Respite Grant Program
C/O Respite Care Association of Wisconsin
P.O. Box 702
Portage, WI
Fax: (608)
IMPORTANT!
The applicant must be fully complete, including signed Satisfaction Survey.
Incomplete applications will not be considered and will be returned.

18. Process
Caregiver/applicant fills out RCAW Caregiver Respite Grant Program
Caregiver/applicant confirms care recipient has applied to long term care support program – whether they were approved or denied.
Caregiver/applicant submits the completed respite application to RCAW
Notification of respite award/denial sent to caregiver/applicant.
If approved, application moves forward.
RCAW Respite Reimbursement staff review application(s) and reviews eligible grants;
Respite reimbursement check is processed and mailed.
Caregiver/applicant proceeds with approved respite and follows up with completed Caregiver Respite Grant Program Satisfaction Survey.
(If Satisfaction Survey is not completed & submitted after respite services provided – it will prevent further respite grants from being awarded.)

19. These funds will only be available until
ACT QUICKLY!!!!
These funds will only be available until
June 30, 2019

20. or info@respitecarewi.org
QUESTIONS?
Contact RCAW at or