Assessment. The case manager assesses the client’s service needs through review of the outcomes of the GAIN assessment and an interview with the client and/or collateral contacts.
Coordination of Services. Based on the needs of the client served, coordination of services includes:
Activities carried out in collaboration with the client.
Coordination across services, support systems and providers.
Outreach to encourage the participation of the client.
Coordination of, or assistance with, crisis intervention and stabilization services, as appropriate.
Assistance with achieving goals for independence as defined by the clients RSS Care Plan.
Optimizing resources and opportunities through:
Enhanced social support networks.
Linkage to Services. The clients served by case management are linked to services and resources to achieve objectives as identified in their individual treatment and RSS plan by the referring agency or agency providing the direct case management services.
Monitoring Client Progress. Monitoring shall include:
Verifying that quality services, as identified in the Comprehensive Service Plan, are being received by the client, and are being delivered by providers in a cost-conscious manner;
Assuring that the client is adhering to the Plan;
Ascertaining the client’s satisfaction with the services provided;
Documenting in the case record the progress of the client;
Ascertaining whether the services to which the client has been referred are and continue to be appropriate to the client’s needs;
Making necessary revisions to the Plan;
Making alternate arrangements when services have been denied or are unavailable to the client.
Planning. Client services planning shall include:
Involving the client, parent, guardian, or spouse/significant other in the definition of goals and the strategies to achieve those goals;
What actions are to be taken, who is responsible for those actions, and the time frames for the actions;
Community reintegration planning;
Exit planning to terminate case management services.