CASE MANAGEMENT

CASE MANAGEMENT A. Definition and Objective Case Management is the term used to describe the many approaches needed to meet the service needs of individuals who are at risk for institutionalization. Case Management is a central issue in the provision of health and social services to aged and disabled individuals. It is the mechanism by which services are coordinated and monitored to these individuals in an effort to provide continuity of care and avoid costly duplication of services. The main objective of Case Management is continuity of services. Ideally, Case Management provides the comprehensive assessment by which an individual's needs for services are determined, arranges for those services in an organized and coordinated way to meet goals and objectives of an individualized service plan, and periodically monitors and reevaluates progress in the attainment of those goals. B Eligibility To be eligible for Case Management Services, individuals must be 60 or older and receiving a Level II score of 22 or above on the DAAS Consumer Information Form. Spouses of case- managed clients are eligible if under 60 and disabled. Information gathered during the assessment process must meet at least four (4) of the following criteria: 1. Without intervention, the client is at risk of inappropriate nursing home placement. 2. The client is suffering a recent loss of a significant other (spouse, etc). 3. The client=s need for assistance with activities of daily living (ADL) exceeds the help available from his/her natural support system. 4. The client needs three or more services or has multiple disabling problems. 5. The client=s behavior is too difficult for family members to manage. 6. The client is isolated or homebound. 7. The client has unresolved medical, social, or psychological problems. 8. The client has a frail or non-existent support system. 9. The client is unable to access the Aging service system. 10. The client is inappropriately institutionalized. C. Units of Service A unit of service equals one (1) case managed hour and includes all activities carried out by the case manager that relate to a client's case. This shall include any travel relating to the client or the case record. One (1) hour of service activity may be counted as a unit of service when a medical assessment is paid out of case management funds. D. Case Management Program Requirements All state and local service providers offering case management service under Title III and SSBG must adhere to the following: All clients are to be entered into the State Approved Client Tracking System no later than 10 working days. 1. Service Activities Phase I: Entry a. Screening: The initial procedure to determine the following: 1) Eligibility for various services based upon socioeconomic data and functional impairment; 2) Whether the client is receiving an appropriate level of service; and, 3) A database of service recipients. The case manager must complete the Consumer Information Form for hospital patients within one working day upon receipt of the referral. Persons in the community must be screened within three working days upon receipt of the referral. In emergencies, the screening must be completed within a 24- hour period. Exceptions will be granted with sufficient justification. (An exception to the three days and the 24-hour period is if the Case Manger is at a maximum caseload and has a waiting list. Case Managers must then refer clients to Information and Referral for referral to formal services or make the appropriate referral to formal services.) b. Intake: The process by which the program has committed to serve the individual in the planning process. At the time of admission into the program, the client will be informed verbally and in writing of the following rights. The client shall: 1) Participate in the development, revision and termination of the plan of care; be informed of all case management services to be provided, and when and how services will be provided; 2) Be given the name, address, telephone number, and function of any person or agency providing care or services to the client; 3) Be given the name, address and telephone number of the designated case manager contact to ask questions, express complaints, report absence of workers, and seek aid in emergencies; (business cards or any other type of communication should be available.) 4) Have the right to refuse any portion of the plan of care; however, refusal of services may cause termination of case management services; 5) Have the right to recommend changes in service or policy to program staff, Area Agency on Aging staff, and State Office staff; 6) Be encouraged to exercise his/her rights to voice complaints and to seek protection from mental, physical and financial abuse, mistreatment and neglect; 7) Be informed both verbally and in writing of the agency's complaint procedures; 8) Be informed of his/her right to review his/her case record; 9) Be discharged from the program according to the discharge procedures stated in the Quality Assurance Standards; 10) Be treated with respect, consideration and full recognition of his/her dignity and individuality; 11) Be shown proper and current identification by any person providing service in their home, (name tags, badges); 12) Have his/her wishes respected regarding home environment and possessions; 13) Be entitled to expect persons coming into the home will exhibit appropriate standards of behavior; and, 14) Be assured of confidentiality regarding his/her case records. Phase II: Assessment Assessment provides the fundamental information upon which all other aspects of case management services are based. A comprehensive assessment must be completed within five (5) working days after completion of the screening. A comprehensive assessment involves obtaining adequate information for implementing plan of care and meeting the informational needs of the assessment. Phase III: Client Goal Setting and Service Planning The formulation of goals and objectives should take place with each client. This enables the client to have an active role in attempting to solve his/her problems. The goals need to be specific, attainable and compatible with the goals of the program. The type of service offered to the client needs to be based on the long range goals or objectives of the client. The plan of care is focused on the needs of the individual, such as activities of daily living. Additional needs of the client also warrant inspection and include counseling, day care and socialization services. Resource Development and Coordination at the community level serves to limit duplication, assist in client targeting, maximize use of limited funds, identify community priorities, and most importantly, to maximize informal support system. Phase IV: Plan of Care Implementation Plan of Care implementation is the follow-through of the objectives that have been stated. The individualized plan for service delivery is based on the assessment of the clients' needs and on resource availability. Phase V: Review and Evaluation of Client's Status Reassessment is necessary to determine if the services being rendered need to be modified, replaced or terminated. Case management is time limited and parameters need to be established for reassessment of the client's condition, reassessment of the effectiveness of the plan and termination of case management activities. This review is to be completed annually. Termination of Case-Managed Client: A client will be terminated from case management services for any of the following reasons: 1) The client or his/her legal representative requests termination; 2) The client no longer meets program eligibility; 3) The client refuses to accept services; or, 4) The client is not available for services after thirty days (30). Each client or legal representative will be informed in writing via the (DAAS-106 Notice of Determination of Service) of the reason(s) for termination ten (10) working days prior to termination. Clients will also be informed of their rights to a hearing. The case manager will assist the client in seeking appropriate care or services, and if necessary, will link the client with the local ombudsman to ease the client's transition into a nursing facility or other long term care facility. 2. Location of Services Case Management services are to be provided in the home of the client. 3. Access to Services A client may enter the system at any time through an appropriate referral. 4. Delivery Characteristics a. The Case Manager shall have control of client records that will be housed in the Case Manager's office. Each client will have a case record that is legible, either handwritten or typed, that will include the following: 1) DAAS-Screening Form - completed annually. 2) DAAS-Assessment - completed at initial intake and annually at the time of recertification. Reassessments and updates may be made more frequently if the client's condition warrants a new assessment. 3) Notice of Determination of Service (DAAS-106) - completed initially to inform the client or legal representative of his/her approval or denial for services. It is also completed any time when services have been reduced or terminated. A copy of the notice will be placed in the case record. 4) Comprehensive Plan of Care DAAS-107 - completed at the initial intake. If changes occur prior to the annual review, update and document in case worker’s monthly review. This must include the client's signature which indicates consent to participate in the program. When annual review is completed, ASignature on File@ will be placed on signature line. 5) Authorization to Release Health/Medical Information (DAAS-105) completed at the time of the initial assessment. 6) Referral and Response for Services (DAAS-104) - completed for services identified in the plan of care. The original is to be mailed to the potential service provider and a copy will remain in the case record until the response is received and becomes a part of the case record. 7) Medical Assessment (DAAS-101) - to be completed initially by the client’s= physician or medical staff person designated by physician. 8) Activity and Units of Service (DAAS-103) - contains documentation of clients' progress, service activities, and units of service for all case management activities. This form also includes documentation of home visits and telephone contacts with the client or service providers, on behalf of the client. Documentation is to be completed within 48 hours of the service activity. The exception will be weekends and holidays when documentation is to be completed the following workday. 9) General Correspondence - Any written communication to or from the informal network on the client's behalf. b. Services are available, but not limited to, five (5) days per week, between 8:00 a.m. and 5:00 p.m. c. Case Record Filing System Material to be filed on the left side (top to bottom): 1) DAAS screening; 2) Signed copy of clients' rights; 3) DAAS 107 - Comprehensive Plan of Care; 4) General Correspondence; 5) DAAS-109 - Referral and Response; 6) DAAS-105 - Authorization to Release Health/Medical Information; 7) DAAS-106 - Notice of Determination/Termination of service. At termination of services, this form will be filed on top to document that case has been closed. Note: The DAAS- screening and DAAS - 107 Comprehensive Plan of Care, will be filed with the most current form on top. Material to be filed on the right side (top to bottom): 1) DAAS-103 - Progress and Assessment Notes; 2) DAAS-104 - Reassessment; 3) DAAS Assessment Instrument; and, 4) DAAS-101 - Medical Assessment. Note: The current DAAS-103 - Progress and Assessment notes will be filed on top. d. Client/Caregiver Satisfaction Survey, DAAS-108 - Survey 20% of clients for client/caregiver satisfaction annually and keep survey in client file or in a separate file. Send a copy to the Division of Aging and Adult Services Case Management Administrator. e. Case Record Retention - A confidential case record will be maintained on each client served and will be protected from damage, theft, and unauthorized inspection by being in a locked/secured cabinet. All client records will be retained for three (3) years after client termination from the program. The case records will be disposed of in a way that will not affect the client or family confidentiality, i.e., shredding or burning. 5. Staffing a. Case Management Supervisor 1) General Statement of Duties: This is an administrative position involving the planning, direction, and administration of the case management program. Supervision of the case manager is a function that is required to ensure that all components of case management are carried out according to the Quality Assurance Standards. Case management supervisors shall operate under the same training and educational requirements as the case manager, and they must meet the qualifications for case managers plus two (2) years of supervisory experience in working with the aged and disabled. 2) Responsibilities: Work involves the application of experienced professional casework and knowledge in staff supervision. Emphasis of work is on planning and program objectives, supervision of casework, staff, evaluation and monitoring of case managers and the services they provide. Work is performed under the general direction of the agency director and is evaluated through written reports, personal conferences, and through the attainment of individual performance objectives. 3) Illustrative Tasks: Plan, assign and supervise the work of case management staff; participate in the hiring and training process; set individual performance objectives; and evaluate employees= performance. Participate with administrative staff in the development of programs and services to resolve the needs of recipients; identify advantages and disadvantages of individual programs and services, and recommend program changes to enhance their effectiveness. Review caseloads and case records of staff each quarter; hold regularly scheduled staff meetings with case management staff to discuss problems and/or successes of the program. Monitor and evaluate program and service activities to ensure the quantity and quality of staff services meets agency requirements, program objectives, and professional standards. Attend conferences, seminars, and professional meetings with service providers to provide or receive information concerning agency programs and services; plan for cooperative interagency relations; remain abreast of current knowledge, trends and developments in the needs of aged and disabled individuals; and perform public speaking as required. Establish and maintain effective communication and working relationships with agencies, community groups, and other public/private service agency providers. Other supervisory activities include: a. Induction of new agency case managers; b. Assessing and understanding the personal strengths, weaknesses, and areas of competency of each case manager; c. Dealing with staff problems as related to service delivery; d. Reviewing cases for consistency and quality of services, and record keeping; e. Serving as a liaison between case managers and agency administration; f. Maintaining the flow of communication; and, g. Performing related work as required. b. Case Manager 1) General Statement of Duties Provide a systematic process of service planning, monitoring, and follow-up to properly meet the needs of individuals who meet the requirements for the Home and Community Based Program. 2) Responsibilities: The case manager is responsible for conducting alone, or as a part of a team, assessments and reassessments, and developing plan of care. The case manager is also responsible for the following activities: a Assessment of the assigned client, developing and initiating an appropriate plan of care, arranging for the provision of services, and monitoring each plan of care; b. Coordinating the efforts of family, friends, or volunteers to provide services to clients; c. Contacting potential service providers to negotiate delivery of services, preparing written referrals to community service agencies, exploring the availability and quality of services, eligibility criteria, and the accessibility of services to the client; d. Arranging for and attending case conferences as needed; e. When appropriate, assisting clients and support systems on a short-term basis; f. Maximizing and coordinating appropriate informal and community resources; g. Monitoring and reviewing continued appropriateness of plan of care, making revisions where necessary; visiting in the home of the client at least monthly; h. Maintaining complete documentation of clients' progress and interaction with service providers, according to the case management documentation standards; completing all applications, forms, and additional documentation as required; and, i. Providing follow-along to ensure quality of care with case reviews that will focus on the individual's progress in meeting goals and objectives established through the plan of care. A Case Manager shall maintain an average, active caseload of 60 clients. A Case Manager who serves as supervisor of case managers shall maintain an active caseload of 50 clients. 3) Qualifications Case Manager a. Education: 1) Master's degree in a behavioral or health related science and two (2) years of related work experience; 2) A Bachelor's degree in a behavioral or related science and two (2) years of related work experience; 3) A Bachelor's degree in any field and four (4) years of related work experience in a human services field preferred, or equivalent experience with the elderly or in case management or social services can be substituted; and, 4) A license to practice as a social worker or nurse in the State of Mississippi with a Bachelor's degree in social work or related field and at least two (2) years of full-time experience in direct services to the aged and disabled clients. b Knowledge: 1) Thorough knowledge of the principles, practices, procedures, and techniques of professional Social Work and Nursing; 2) Knowledge and understanding of psychological, social, health, rehabilitation principles, practices, and economic factors influencing the attitudes and behavior of individuals and families; 3) Knowledge of community resources available to individuals and families, and an interest in mobilizing the specialized function into a more coordinated and comprehensive system; 4) Knowledge and skill in interviewing and assessment techniques; and, 5) Ability to work in a team relationship. 6. Training: Case management supervisors and case managers are required to complete the following training: a. All new case management staff must receive agency induction training and in-service education, or staff development as required by the Area Agency on Aging and/or the service provider. b. All case management staff are mandated to participate in orientation and training activities scheduled by the Division of Aging and Adult Services Case Management Administrator and any other training activities designated by the Case Management Administrator. Orientation shall include: 1) Introduction to the agency and the organization of the Aging network; 2) Overview of the program history, intent and target population; 3) Introduction to community resources; 4) Review of agencies and services, policies, procedures, and applicable service regulations. c. New case management staff shall participate in a program orientation by the Case Management Administrator and a minimum two (2) day field training experience under the supervision of a case manager at the designated training site. d. Agencies providing case management must have a system in place for identifying the training needs of staff. This training is provided to help staff in performing their case management activities. e. Field training experience for case managers and case management staff shall include: 1) Observing and working with a designated case manager(s) specifically receiving training on how to perform all case management functions, including home visits; 2) Completion of all required forms; 3) Development of a comprehensive plan of care based upon client needs; and, 4) Protocol for working with any agency staff in arranging services. f. Ongoing training will be provided to all case management staff to enhance their knowledge and skills through in-service training, conferences and workshops, and academic course work. All training activities shall be documented by the Area Agency on Aging and shall be made available to the Division of Aging and Adult Services Case Management Administrator upon request. 7. Monitoring, Evaluation and Reporting Monitoring includes performing necessary activities to determine the delivery of case management activities. a. The Office of Monitoring and Evaluation shall monitor case management annually with periodic reviews at the discretion of the Division of Aging and Adult Services. b. The Case Management Supervisor shall monitor and evaluate case managers annually. c. The Area Agency on Aging shall monitor the case management program and/or case management service provider annually. d. The Division of Aging and Adult Services case management quarterly reporting form is to be completed within five (5) working days after the end of each quarter. It will then be mailed to the Case Management Administrator within ten working days after the end of the quarter. 8. Personnel Management The Area Agency on Aging and/or provider agency shall have a personnel management system in place to include the following: a. A written job description and a listing of qualifications for all case management staff; b. An established wage scale for each job category; and, c. Written personnel policies that include at a minimum: 1) Recruitment and selection process; 2) Benefits; 3) Leaves and absences; 4) Hours of employment or methods of scheduling; 5) Evaluation procedures to include a copy of the performance assessment; 6) Discipline or termination procedures; and, 7) Grievance procedures/appeal process. d Personnel policy and procedures shall be made available to the Division of Aging and Adult Services Case Management Administrator upon request. 9. Prohibited Case Manager Services Activities: a. Direct services other than case management are not to be provided by the case manager; b. Lending or borrowing money or articles, to or from the clients; c. Driving or riding in the client's automobile; d. Transporting the client in the case manager's automobile; e Smoking in the client's home; f. Breach of client=s confidentiality; and, g. Consumption of alcoholic beverages in the client's home or prior to service delivery.