Our Services.
Case Management services are available for all CAP/DA participants.
Maggie Janes, as the Case Management Entity, is responsible for care coordination through assessing, care planning, referring or linking and monitoring and following-up.
Case Management and Care Coordination services are necessary to identify needed medical, social, environmental, financial, and emotional needs to avert adverse occurrences.
These services are provided to maintain the participants health, safety, and well-being in the community. It is a required component of the CAP/DA waiver that a Case Management activity is performed at least monthly and a multidisciplinary case management assessment of health, safety and well-being is performed quarterly.
Case Management Services.
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 system.
-Reassess periodically to determine whether a beneficiary’s needs or preferences have changed 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 beneficiary. Services are provided according with all requirements specified in this policy: all applicable federal and state laws, rules, and regulations.
Make it stand out.
Referral and Linkage.
Referral and related activities link a beneficiary 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 managers or care advisors to identify what services and interventions do and do not work and what other potential service and intervention 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 beneficiary, responsible party, and service providers can be conducted to ensure that the service plan is effectively implemented and adequately addresses the needs of the beneficiary.
Case Management Responsibilities.
Develop.
Develop procedures in accordance with NC Medicaid standards and local policy.
Ensure.
Ensure waiver and non-waiver services are accurately listed on the POC initially, annually and during a POC revision.
Educate.
Educate the caregiver of children, the elderly and disabled adult community about waiver services.
Monitoring.
Provide regular and routine beneficiary monitoring to assure health, safety and well-being, quality assurance reporting and beneficiary risk mitigation.
Provide.
Provide help in obtaining medical documentation to monitor ongoing care needs .
Complete.
Complete critical incident reports within time frame alloted of the incident.
Assess.
Assess participants initially and annually at minimum to determine ongoing appropriateness of services.
Maintain.
Maintain an Advisory Committee that supports the local program in developing and improving resources for a CAP/DA participant; and advocating for the CAP/DA program within the community.