Case Management 535-05-35

(NEW 1/1/09 ML #3172)

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Case management for an individual applying for or receiving personal care services shall be the responsibility of a county social service board HCBS case manager except when the individual is also receiving a service(s) through the developmental disabilities division. Case management for personal care services for an individual receiving a service(s) through the DD division shall be the responsibility of a DD case manager. If the individual is not receiving service(s) through the DD Waiver, they have the right to choose the provider of case management services.

 

The case manager is responsible for assessing an individual’s needs for personal care services, developing a comprehensive care plan that includes identification of tasks and times required to perform tasks, assisting the individual with obtaining a personal care service provider, monitoring and reassessing needs on a periodic basis, and terminating services when appropriate.

 

The case manager must schedule an appointment for an initial assessment no later than 5 working days after receiving a request for personal care services and must complete an initial comprehensive assessment no later than 10 working days after receiving a request for personal care services. All contacts with an individual must be documented in the case file.

 

The case manager shall visit with an individual in his/her place of residence every six months and review and update the assessment and the individual’s care plan as necessary.

 

A comprehensive assessment must be completed initially and annually thereafter for the individual or if there has been a significant change in personal care needs. The comprehensive assessment must include information on the individual’s physical health, cognitive and emotional functioning, ability to perform activities of daily living or instrumental activities of daily living, informal supports, need for 24 hour supervision, social participation, physical environment, financial resources, and any other pertinent information about the individual or his/her environment.

 

After completing the comprehensive assessment, the case manager and individual work together to develop a plan for the individual's care based on the individual’s needs, situations, and problems identified in the assessment. The individual and case manager work together to develop a comprehensive plan of care that is recorded in the individual’s case file, authorized on the Authorization to Provide Personal Care Services SFN 663, and summarized on the Personal Care Services Plan SFN 662. The plan must include:

  1. All problems identified, including those that will not be addressed through the provision of personal care services.
  2. Desired outcome(s) for each problem must be documented in the comprehensive assessment for which units of personal care services have been authorized.
  3. The type(s) of help needed to achieve each desired outcome.
  4. Services and providers that can supply the need for help.
  5. Provider(s) the individual selects.
  6. The amount of personal care service to be provided and the specific time-period.
  7. Documentation of the medical necessity to monitor vital signs and identify who is to be notified of an individual’s vital signs readings.

The case manager shall identify personal care service providers available to provide the service required by the individual and provide the following information to the individual:

  1. Name, address and telephone number of available personal care service providers.
  2. Identify whether a provider is an agency or individual QSP or a basic care assistance provider.
  3. Any limitations applicable to the available providers.
  4. If applicable, any global or individual specific endorsements for specialized cares that available providers are qualified to perform.  

The individual must select the personal care service provider(s) they want to deliver the service to meet their care needs. The case manager must then complete an Authorization to Provide Personal Care Services, SFN 663, for each provider selected and finalize the Personal Care Services Plan, SFN 662.

 

The case manager must monitor and document that the individual is receiving the personal care services authorized on SFN 663. The case manager must review the quality and quantity of services provided. A reassessment of the individual’s needs and care plan must be completed at a minimum of six-month intervals.

 

The case manager is responsible for following Department established protocols when abuse, neglect or exploitation of an individual is suspected.

 

An individual qualifying for personal care services shall receive targeted case management services for individuals in need of long term care services if the individual is not receiving case management under any HCBS waiver or other targeted case management provision.

 

 

Targeted Case Management Eligibility Requirements:

 

The individual receiving TCM will meet the following criteria:

  1. Medicaid recipient.
  2. Be over 65 years of age, or be under 65 years of age and meet Social Security disability criteria.
  3. Not currently be covered under any other case management/targeted case management system.
  4. Not a recipient of HCBS (1915C Waiver) Service.
  5. Lives in the community and desires to remain there; or be ready for discharge from a hospital within 7 days; or resides in a basic care facility; or reside in a nursing facility if it is anticipated that a discharge to alternative care is within six months.
  6. Has “long-term care need.” Document the required “long-term care need” on the Application for Services, SFN 1047. The applicant or legal representative must provide a describable need that would delay or prevent institutionalization.
  7. The focus or purpose of TCM is to identify what the person needs to remain in their home or community and be linked to those services and programs. The applicant or referred individual must agree to a home visit and provide information in order for the process to be completed.
  8. An assessment be completed and a care plan be developed. The TCM client’s case file must contain documentation of eligibility for TCM. This should be accomplished by the Application for Service and completion of a comprehensive assessment.
  9. Targeted case management is considered a “medical need” and thus included as a health care cost.  Use of Medicaid funding for targeted case management may result in the recipient paying for/toward the cost of their case management. The client must be informed of that fact by noting Case Management Service and cost on the Personal Care Service Plan. Clients must also check and sign acknowledgment that if they are on Medicaid they may have a recipient liability. Payments from the Medicaid Program made in behalf of recipients 55 years or older are subject to estate recovery including for Targeted Case Management.

If case management is not provided under any waivered service, Targeted Case Management must be identified on the Personal Care Services Plan, SFN 662.  

 

An individual must be given a “Your Rights and Responsibilities” brochure, DN 46 (available through Office Services), and verification of receipt of the brochure must be noted on SFN 1047, Application for Services, or in the documentation of the assessment.