Targeted Case Management: PDF Print E-mail

Targeted case management is required for all individuals who participate in the waiver. Case managers provide a variety of functions critical to insure that services and supports address not only the familyholdhands_200health and safety needs of individuals receiving waiver funding, but also reflect the needs and preferences reflected in the person-centered Plan of Care. The individual/legally responsible person, the LME, the provider agencies and the case manager have a role in assuring that the proper services are delivered as planned to meet the person's needs. The case manager has overall responsibility for coordinating and monitoring the CAP-MR/DD services approved on the Plan of Care. In addition, the case manager coordinates the CAP-MR/DD services with other services, resources and supports available in the community, including supports provided by the person's family and friends. The case manager reviews/monitors all aspects of service delivery. The source of funding of a service does not affect the case manager's responsibilities regarding coordinating of, observing, monitoring and linking the person to services and supports. The individual/legally responsible person assists the case manager, provider agencies and planning team in arranging and coordinating services.

This includes informing the case manager of changes in situation and/or needs, cooperating in scheduling services and allowing required monitoring to occur. The person/responsible party should never sign or be asked to sign information that is blank or inaccurate. In addition, the case manager is responsible for obtaining new signatures from the individual/legally responsible party if the Plan of Care is revised after the original signatures were obtained, but before the plan is presented to the local approval unit.

More specifically, case management responsibilities include:

  • Coordination and oversight of assessment and reassessment of the individual's level of care and need for services and supports. This includes coordination of any assessments needed by the individual as identified during diagnostic assessment.
  • Facilitation and development of the person-centered Plan of Care.
  • Submission of the initial Plan of Care, continued need reviews, and revisions to the Plan of Care to the LME service authorization unit or local approver.
  • Initiation of services through completion of service order for authorized services. The case manager arranges the CAP-MR/DD services approved on the Plan of Care using a service order. Services are expected to be implemented within 45 days of Plan of Care approval.  The case manager issues written orders for CAP-MR/DD services approved on the Plan of Care, or arranges for service orders if the services require orders from another individual. The order is sent to the provider agency with a copy of the entire Plan of Care before services are initiated. The LME maintains a copy. Provider agencies are notified in writing if a service order is discontinued. See the DMH/DD/SAS Services Records Manual for service order requirements.
Service orders are not required for equipment/supplies billed through the LME/ Lead Agency. A copy of the physician's signature certifying medical necessity is included with the request for Specialized Equipment and Supplies and maintained on file by the LME.

  • Support and assistance to individuals/legally responsible person during any grievance or appeals process, including provision of appeal rights.
  • Locating and coordinating services and supports. Though the case manager does not control the provision of other services, the case manager must be aware of other services and supports being provided and how these services/supports are being provided. The case manager works with others involved with the person to help assure proper care and treatment, prevent duplication of services, and coordinate the services with the CAP-MR/DD services. The case manager reports any problems or concerns about a service to the responsible provider agency. The case manager also assists the person/legally responsible person in working with the service provider agencies. It is important that the case manager also coordinate and promote the use of natural supports in planning services and supports with the person/legally responsible person and the planning team.
CAP-MR/DD is not intended to replace or duplicate other services and resources that are available to the person. The case manager assures that the person gets the best available treatment and care by carefully coordinating the CAP-MR/DD services with other services as well as the resources available in the community. For those persons with a broader array of needs than can be met with CAP-MR/DD, it is essential that the case manager fully utilize all resources to allow the individual to stay in the community. The case manager, with the person/legally responsible person and planning team, must look beyond just buying CAPMR/DD services and explore what the community has to offer. This may include seeking assistance from community groups, private individuals, public agencies, and other entities.

  • Monitoring of service delivery to assure quality of care as well as continued appropriateness of services.
The case manager is responsible for monitoring CAP-MR/DD services and all other services provided to the person as well as the overall care of the person. This activity also helps the case manager continually evaluate the person's need to participate and benefit in CAP-MR/DD. The frequency of monitoring is specified in the Plan of Care but there must be no less than one face to face visit per month. Face to face visits must include periodic visits to the home of the recipient at a minimum of every six months.

The case manager reviews the provision of services as provided versus the ordering of those services and considers if those services are meeting their intended purpose. The case manager looks at the provider agency's performance and the person's response to the service, and then determines the need for adjustments in the service. Documentation of monitoring and the actions taken/planned as a result of the monitoring must be recorded in the person's record. The monitoring schedule must be sufficient to assure the health, safety and welfare of the person.

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