	Case Management Services: Case Management; Care Coordination; Intensive Case Management

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-CM 4: Service Planning and Coordination

Each individual or family participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

Interpretation: Services needed or requested by individuals and families may include the following:

For all individuals and families: other services needed to maintain and preserve independence or to promote or recover optimum social, psychological, and physical development and functioning.

For individuals, families, and children: mental health or other counseling services, group activity and/or recreation programs, volunteer or employment programs, homemaker services, foster care, intergenerational support services, vocational training, and child care.

For individuals with special needs: counseling, drug and alcohol dependency treatment, transitional living arrangements, residential treatment or other out-of-home placement, education, day treatment or activity programs, nutrition services, vocational training or rehabilitation, and transportation services.

For older adults: mental health or other counseling services, medical and rehabilitative services, escort/transportation services, social programs, volunteer or employment programs, in-home care services, skilled nursing services, senior companion or intergenerational support services, home delivered meals, telephone reassurance services, repair services, day care and respite services, and legal and financial services.

PA-CM 4.01

All individuals and families receive:

a service plan;
direct provision of, or referral for services, as necessary; and
individual case coordination and monitoring of services.

Note: When the population served is mobile, for example, in the aftermath of a disaster, an integrated service plan and exit plan may be initiated.

PA-CM 4.02

A service plan is developed in a timely manner with the full participation of the individual or family, and an expedited service planning process is available when crisis or urgent need has been identified.

Interpretation: Service planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and assuming more responsibility for making decisions. When the service recipient is a minor, or an adult under the care of a guardian, the agency should follow applicable state laws or regulations requiring involvement or consent of service recipients' legal guardians.

PA-CM 4.03

The service plan is based on the assessment, and includes:

agreed upon goals, desired outcomes, and timeframes for achieving them;
services and supports to be provided, and by whom; and
the individual’s or guardian’s signature, as appropriate.

PA-CM 4.04

During the service planning process the agency explains:

available options;
how the agency can support the achievement of desired outcomes; and
the benefits, alternatives, and risk or consequences of planned services.

PA-CM 4.05

The service plan addresses, as appropriate:

unmet service and support needs;
possibilities for maintaining and strengthening family relationships; and
the need for support of the individual’s or family's informal social network.

PA-CM 4.06

Case management services:

directly provide, refer, contract, or otherwise arrange for individuals and families to receive needed or requested services as identified in the service plan; and
maintain a comprehensive, up-to-date list of community programs and services, and information on how to access them.

Research Note: Research suggests that mental health service recipients achieve better outcomes when case managers provide services directly, rather than only making referrals.

Research Note: An evaluation of 25 HUD-funded community Continuums of Care (CoC) for homeless people showed that more homeless people used more programs and services as a result of using the CoC approach than had done so prior to implementing the CoC approach. Homeless continuums of care include prevention, outreach, assessment, shelter, transitional housing, permanent supportive housing, and supportive services at all levels.

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	PURPOSE: Individuals and families who receive Case Management Services access and use resources and supports that build on their strengths and meet their service needs.

RELATED FILES


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	VOLUNTEER An individual who performs services for an organization for civic, charitable, or humanitarian reasons, without promise, expectation, or receipt of compensation for services rendered. Such service must be offered freely and without pressure or coercion, direct or implied, from an employer. If the individual is otherwise employed by the same employer for which s/he volunteers, the individual cannot volunteer to perform the same type of services that s/he is paid to perform as an employee.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


	SPECIAL NEEDS A designation used in reference to conditions or characteristics of a person that reflect a need for special care, services, or treatment. When the term is used in the context of adoption services, special needs refers to conditions that make a child harder to place for adoption. This includes children who are members of sibling groups, older children, children with disabilities, children of certain racial /ethnic backgrounds, etc. When the term is used in the context of foster care it refers to the need for a higher degree of specialized case services and attention due to mental and physical disabilities. When the term is used in the context of out-of-school time services, a child or youth may have special physical, behavioral, medical, emotional, or cognitive needs that should be addressed or accommodated. The term is also used in other contexts. See also DEVELOPMENTAL DISABILITIES.


	MONITORING An evaluation involving a periodic review of consumer services, organizational activities, or conduct. Specifically, monitoring is an activity of case coordination, whereas more broadly, monitoring is an evaluation technique used in overall quality assurance.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	MANAGEMENT See ADMINISTRATION


	CONTRACT A formal written agreement between two or more parties that specifies the services, space, or products to be provided in exchange for some form of compensation. Also known as "purchase of service arrangement."


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	RESEARCH For purposes of COA accreditation, all forms of internal or external research involving persons served except internal program evaluation and outcomes research, or educational projects performed by students and interns that are part of their professional training.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	REFERRALS Resource suggestions provided to consumers to address problems or needs that are beyond the scope of the organization's mission.


	EVALUATION The review and assessment of organizational operations, programs and services.


	PREVENTION Actions taken to minimize and/or eliminate social, psychological, or other conditions. Prevention can occur at the individual, group, community, and societal levels and enhances opportunities to achieve positive fulfillment.


	OUTREACH Contact initiated by a provider to identify persons in need of services, to provide information to them about services and benefits, and to encourage the use of appropriate services.