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

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-CM 5: Service Monitoring and Re-Assessment

Service monitoring ensures continuity of service and care and timely adjustments to service provision when the individual’s or family’s needs and circumstances change.

PA-CM 5.01

Service monitoring includes:

confirmation, usually within one or two working days, that a service has been initiated as scheduled;
verification, usually within 15 working days, that the service is appropriate and satisfactory;
follow-up every three months; and
immediate response to any complaints or problems that develop in the delivery of service or with the person receiving services.

Interpretation: The agency tailors the type and frequency of service monitoring according to the needs of persons receiving services, frequency and intensity of service provided, and frequency of contact with informal caregivers and cooperating providers.

PA-CM 5.02

Every individual participates in a formal re-assessment annually, or more frequently when indicated.

PA-CM 5.03

An event-based re-assessment is conducted:

within five working days of a precipitating event;
when there is a change in the individual or family’s status or circumstances, or a new issue arises; and
within 48 hours of notification that hospital or institutional discharge is imminent.

Interpretation: An agency that, due to contractual requirements, is unable to conduct event-based re-assessments according to these timeframes can modify them to meet the needs and goals of the population served.

PA-CM 5.04

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:

service plan implementation;
the service recipient's progress toward achieving goals and desired outcomes; and
the continuing appropriateness of agreed upon service goals.

Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker's supervisor reviews a sample of the worker's evaluations as per the requirements of the standard.

Timeframes for the review should be adjusted depending upon issues and needs of persons receiving services and frequency and intensity of services provided.

PA-CM 5.05

The worker and family regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.

QUICK JUMP TO


	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.


	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.


	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."


	CAREGIVER The provider of physical, emotional, and social needs to another person, often dependent and unable to provide for his or her own needs. Caregiver is the generic term used for the direct service providers in Community Care and Support Services (CCS).


	SAMPLE A portion or representative percentage of a greater whole.


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


	SERVICE GOALS Broad, issue-oriented statements that reflect the realistic achievements to be accomplished in the short or long term. Goals are achieved through the accomplishment of specific quantifiable objectives.


	MANAGEMENT See ADMINISTRATION