Case Management Tasks.
Assessment.
Case Managers shall conduct an annual comprehensive assessment to:
Assess all aspects of the participant, including medical, physical, functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, vocational, educational and other areas.
Identify needs to prevent health and safety factors to assist in maintaining community placement.
Consult with informal and paid providers such as family members, medical and behavioral health providers, and community resources to ensure the assessment adequately reflects needs to be met through the service plan.
Review completed assessment IAE and other summary information to assist with identifying care needs, risk indicators and support systems.
Reassess periodically to determine whether a participants needs or preferences has changed and to make a recommendation for change in status assessment of need.
Care Planning.
Care planning is the development and periodic revision of a person-centered service plan based on the information collected through the assessment and reassessment process. The service plan identifies all formal services received in the amount, frequency and duration. The service plan also identifies both formal and informal supports to assure the health, safety and well-being of the participant. Services are provided according with all requirements specified in the clinical coverage policy: all applicable federal and state laws, rules and regulations.
Referral and Linkage.
Referral and related activities link a participant with medical, behavioral, social, and other programs, services and supports to address identified needs and achieve goals specified in the service plan. The case manager or care advisor shall coordinate with other human services agencies as specified in the service plan.
Monitoring and Follow-up.
Monitoring and follow-up are key tasks for the Case Manager or Care Advisors to identify what services and interventions do and do not work and what other potential service and interventions can be arranged to address an ongoing or newly assessed need. When a case manager is performing monitoring and follow-up activities, announced and unannounced visits with the participant, responsible party, and service providers can be conducted to ensure that the service plan is effectively implemented and adequately addresses the needs of the participant.