| (a) Assessment. An individual is assessed according
to §412.406 of this title (relating to Authorization for MH Case
Management Services) to determine the LOC necessary to address the
individual's needs. If the individual needs either routine or intensive
case management the provider must assign a case manager according
to §412.404(b) of this title (relating to Provider Requirements).
MH case management services, as well as attempts to provide case management,
must be documented according to §412.413 of this title (relating
to Documenting MH Case Management Services).
(1) MH case management services must:
(A) be delivered according to the department's utilization
management guidelines, which are described in §412.415 of this
title (relating to Fair Hearings and Appeal Processes); and
(B) include regular, but at least annual, monitoring
of service effectiveness and proactive crisis planning and management.
(2) Case managers must recognize that:
(A) an LAR as authorized by law may act on behalf of
an individual in matters such as accepting or declining services;
and
(B) a primary caregiver who is not the individual's
LAR is included in recovery planning and discussions that relate to
the individual if written permission is obtained from the individual
or LAR.
(b) Routine case management. Routine case management
is provided to eligible adults, children, or adolescents and is primarily
a site-based service. A case manager assigned to an individual who
is authorized to receive routine case management services must:
(1) meet face-to-face with the individual and the individual's
LAR or primary caregiver within 14 days after the case manager is
assigned to the individual or document why the meeting did not occur;
(2) assist the individual in identifying the individual's
immediate needs and in determining access to community resources that
may address those needs;
(3) identify the strengths, service needs, and assistance
required to address the identified needs;
(4) identify the goals and actions required to meet
the individual's identified needs;
(5) specify the goals and actions to be accomplished;
(6) develop a timeline for obtaining the needed services;
(7) take the steps that are necessary to accomplish
the goals required to meet the individual's identified needs by using
referral, linking, advocacy, and monitoring;
(8) meet face-to-face with the individual upon the
individual's, the LAR's, or the primary caregiver's request, or document
why the meeting did not occur;
(9) reassess the individual's needs at least annually
or as changes occur;
(10) meet face-to-face with the LAR, with or without
the child or adolescent being present, to provide a service that
assists the child or adolescent in gaining and coordinating access
to necessary care and services;
(11) meet face-to-face with the individual and the
LAR or primary caregiver upon notification of a clinically significant
change in the individual's functioning, life status, or service needs,
or document why the meeting did not occur;
(12) if notified that the individual is in crisis,
coordinate with the appropriate providers of emergency services to
respond to the crisis, as described in Chapter 412, Subchapter G,
specifically §412.321 of this title (relating to Crisis Services);
and
(13) develop a timeline for reevaluating the individual's
needs.
(c) Intensive case management. Intensive case management
is provided to eligible children and adolescents and is primarily
community-based. A case manager assigned to a child or adolescent
who is authorized to receive intensive case management services must:
(1) develop an intensive case management plan (plan)
based on the child's or adolescent's needs that may include information
across life domains from relevant sources, including:
(A) the child or adolescent;
(B) the LAR or primary caregiver;
(C) other agencies and organizations providing services
to the child or adolescent;
(D) the individual's medical record; and
(E) other sources identified by the individual, LAR,
or primary caregiver;
(2) meet face-to-face with the child or adolescent
and the LAR or primary caregiver:
(A) within seven days after the case manager is assigned
to the child or adolescent;
(B) within seven days after discharge from an inpatient
psychiatric setting, whichever is later; or
(C) document the reasons the meeting did not occur;
(3) meet face-to-face with the child or adolescent
and the LAR or primary caregiver according to the child's or adolescent's
plan or document why the meeting did not occur;
(4) identify the child or adolescent's strengths, service
needs, and assistance that will be required to address the identified
needs in the plan;
(5) comply with subsection (b)(4) - (13) of this section;
(6) incorporate wraparound process planning or other
department-approved model in developing a plan that addresses the
child's or adolescent's unmet needs across life domains, in accordance
with the department's utilization management guidelines and subsection
(d) of this section;
(7) take steps that are necessary to assist the child
or adolescent in gaining access to the needed services and service
providers, including:
(A) making referrals to potential service providers;
(B) initiating contact with potential service providers;
(C) arranging, and if necessary to facilitate linkage,
accompanying the child or adolescent to initial meetings and non-routine
appointments;
(D) arranging transportation to ensure the child's
or adolescent's attendance;
(E) advocating with service providers; and
(F) providing relevant information to service providers;
(8) monitor the child's or adolescent's progress toward
the outcomes set forth in the plan, including:
(A) gathering information from the child or adolescent,
current service providers, LAR, primary caregiver, and other resources;
(B) reviewing pertinent documentation, including the
child's or adolescent's clinical records, and assessments;
(C) ensuring that the plan was implemented as agreed
upon;
(D) ensuring that needed services were provided;
(E) determining whether progress toward the desired
outcomes was made;
(F) identifying barriers to accessing services or to
obtaining maximum benefit from services;
(G) advocating for the modification of services to
address changes in the needs or status of the child or adolescent;
(H) identifying emerging unmet service needs;
(I) determining whether the plan needs to be modified
to address the child's or adolescent's unmet service needs more adequately;
(J) revising the plan as necessary to address the child's
or adolescent's unmet service needs;
(K) a description of the intensive case management
services to be provided by the case manager; and
(L) a statement of the maximum period of time between
face-to-face contacts with the child or adolescent, and the LAR or
primary caregiver, determined in accordance with the utilization management
guidelines.
(d) Wraparound process planning. Wraparound process
planning or other department-approved model may include, but is not
limited to:
(1) a list of identified natural strengths and supports;
(2) a crisis plan developed in collaboration with
the LAR, caregiver, and family that identifies circumstances to determine
a crisis that would jeopardize the child's or adolescent's tenure
in the community and the actions necessary to avert such loss of tenure;
(3) a prioritized list of the child's or adolescent's
unmet needs that includes a discussion of the priorities and needs
expressed by the child or adolescent and the LAR or primary caregiver;
(4) a description of the objective and measurable outcomes
for each of the unmet needs as well as a projected time frame for
each outcome;
(5) a description of the actions the child or adolescent,
the case manager, and other designated people take to achieve those
outcomes; and
(6) a list of the necessary services and service providers
and the availability of the services.
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