CHAPTER 5221. MENTAL HEALTH INTENSIVE
CASE MANAGEMENT
GENERAL PROVISIONS Sec.
5221.1. Scope.
5221.2. Objective.
5221.3. Definitions.
GENERAL REQUIREMENTS
5221.11. Provider participation.
5221.12. Consumer eligibility.
STRUCTURE AND ORGANIZATION
5221.21. Organizational requirements.
5221.22. Relationship to other parts of the system.
5221.23. Staffing patterns and limits.
RESPONSIBILITIES
5221.31. Responsibilities of providers.
5221.32. County administrator.
5221.33. Intensive case management records—statement of policy.
RECORD AND PAYMENT REQUIREMENTS
5221.41. Recordkeeping.
5221.42. Payment.
5221.43. Quality assurance and utilization review.
5221.44. Conflict of interest.
CONSUMER RIGHTS
5221.51. Consumer preparation and freedom of choice.
5221.52. Notice of confidentiality and nondiscrimination.
5221.53. Recipient right of appeal.Authority The provisions of this Chapter 5221 issued under section 201(2) of the Mental Health and Mental Retardation Act of 1966 (50 P.S. § 4201(2)), unless otherwise noted.
Source The provisions of this Chapter 5221 adopted December 21, 1990, effective December 22, 1990, and apply retroactively to March 4, 1989, 20 Pa.B. 6276, unless otherwise noted.
Cross References This chapter cited in 55 Pa. Code § 6100.2 (relating to applicability).
GENERAL PROVISIONS
§ 5221.1. Scope.
This chapter establishes minimum standards for the provision of intensive case management for targeted adults with serious and persistent mental illness and children with a serious mental illness or emotional disorder. It is applicable to county administrators and to providers approved by the Office of Mental Health to provide intensive case management services.
§ 5221.2. Objective.
Intensive case management is established as a primary, direct service to the targeted population. It is designed to insure access to community agencies, services and people whose functions are to provide the support, training and assistance required for a stable, safe and health community life. Services will be offered within the parameters imposed by funding and other resources.
§ 5221.3. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Case—A consumer and members of his family being served, if the consumer is a child.
Child—A person 17 years of age or younger or 21 years of age or younger if enrolled in special education.
Consumer—A person who receives intensive case management services. The term does not include a family member who receives services.
County administrator—The MH/MR administrator who has jurisdiction in the geographic area.
County plan—A county plan and estimate of expenditures which describes how case management services will be made available, including the anticipated expenditures for the services. The plan is prepared and updated annually by the county administrator and the county MH/MR board and submitted for approval to the Department of Human Services, Office of Mental Health in accordance with this chapter.
Department—The Department of Human Services of the Commonwealth.
Emotional disturbance—A child’s inability to function in the home, school or community and so the child requires multiple medical, social, educational or other supports.
Enrolled provider—A county MH/MR program or private agency specifically identified as a provider of intensive case management in the county human services plan which has been approved by the Department and enrolled by the Office of Mental Health and the Office of Medical Assistance Programs for claims processing.
Family—Parents, as defined in this section, siblings and other relatives living in the home.
Global assessment of functioning scale—A procedure for measuring the overall severity of psychiatric disturbance which is contained in DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised), published by the American Psychiatric Association, 1987, Washington, D.C., and subsequent editions.
Intensive case manager—A staff person designated to provide intensive case management under § 5221.21 (relating to organizational requirements).
Intensive case management—The services described in this chapter which are designed to assist targeted adults with serious and persistent mental illness and targeted children with a serious mental illness or emotional disorder and their families, to gain access to needed resources, such as medical, social, educational and other services.
MH/MR—Mental Health/Mental Retardation.
Mental health direct care experience—Working directly with adult or children mental health service consumers, providing services involving casework or case management, individual or group therapy, crisis intervention, early intervention, vocational training, residential care or social rehabilitation in a mental health facility or in a facility or program that is publicly funded to provide services to mental health consumers, or in a nursing home, a juvenile justice agency, or a children and adolescent service agency.
Mental illness—The existence of a mental disability subject to DSM III-R diagnosis, excluding mental retardation or substance abuse as the primary diagnosis, rendered by a licensed physician or psychologist.
Parent—The biological or adoptive mother or father or the legal guardian of the child or a responsible relative or caretaker with whom the child regularly resides.
Supervisor—A person designated to supervise intensive case managers under § 5221.21.
Targeted population—Adults with serious and persistent mental illness and children with serious mental illness or emotional disorders who are deemed eligible to receive intensive case management as identified by the county administrator under this chapter.
GENERAL REQUIREMENTS
§ 5221.11. Provider participation.
(a) County MH/MR programs and public and private agencies are eligible to enroll as intensive case management providers if they are specifically designated as providers in an approved county plan. The Department reserves the right to limit providers to those it considers best able to serve the targeted population.
(b) County MH/MR programs and public and private agencies seeking to provide intensive case management shall apply to the county administrator to be included in the county plan.
(c) Providers approved by the Department shall sign a provider agreement, as specified in Chapter 1101 (relating to general provisions), to participate as providers of intensive case management.
(d) Enrolled providers shall complete a Multi-Category Enrollment Information Packet which will permit Federal share reimbursements through Medical Assistance.
(e) Enrolled providers shall abide by Chapter 1101, to the extent that the compliance is consistent with compliance with this chapter.
§ 5221.12. Consumer eligibility.
(a) Persons eligible for intensive case management are:
(1) Adults, 18 years of age or older, who have a serious and persistent mental illness. A person shall be considered to have a serious and persistent mental illness when two of the following criteria are met:
(i) Diagnosis—Schizophrenia or chronic major mood disorder (diagnosis codes 295 and 296 in the DSM III-R).
(ii) Treatment history—One of the following:
(A) Admission to State mental hospitals totaling 60 days within the past 2 years.
(B) Two admissions to community inpatient psychiatric units totaling 20 or more days within the past 2 years.
(C) Five or more face-to-face encounters with emergency services personnel within the past 2 years.
(D) Three or more years of continuous attendance in a community mental health service, at least one unit of service per quarter.
(E) History of sporadic course of treatment as evidenced by at least three missed appointments within the past 6 months, inability to or unwillingness to maintain medication regimen or involuntary committment to outpatient treatment.
(iii) Functioning level. One of the following:
(A) Global Assessment of Functioning Scale (DSM-III-R, pages 12, and 20) ratings of 40 and below.
(B) A rating of 60 and below if the person is 35 years of age or younger or has a history of aggressive or violent behaviors.
(2) Adults who were receiving intensive case management services as children and were reviewed by the provider and approved by the county administrator as needing intensive case management services beyond the date of transition from child to adult.
(3) Children who are mentally ill or emotionally disturbed and who meet one of the criteria described as follows:
(i) Children, 6 years of age or younger, who are enrolled in, or require, early intervention services under section 671 of the Education of the Handicapped Act (20 U.S.C.A. § 1400).
(ii) Children who, with their families, are receiving services from three or more publicly funded programs such as, Medical Assistance, Aid to Families with Dependent Children and Special Education.
(iii) Children who are returning from State mental hospitals, community inpatient units or other out-of-home placements, including foster homes and juvenile court placements.
(iv) Children who are recommended as needing mental health services by a local interagency team which shall include county agency representatives.
(4) Families of eligible children who are receiving intensive case management services.
(b) Exceptions. An adult or child receiving, or who needs to receive, mental health services but who does not meet the requirements of this section is eligible for intensive case management upon review and recommendation by the county administrator and written approval by the Department’s area office of mental health.
(c) Termination. Intensive case management may be terminated for one of the following reasons:
(1) Determination by the consumer or the parent of a child receiving the service that intensive case management is no longer needed or wanted.
(2) Determination by the intensive case manager in consultation with his supervisor or the director of intensive case management, and with written concurrence by the county administrator that intensive case management is no longer necessary or appropriate for the adult or child receiving the services.
STRUCTURE AND ORGANIZATION
§ 5221.21. Organizational requirements.
Intensive case management providers shall ensure that the following organizational requirements are met:
(1) The intensive case management program shall be organized or identified as a separate unit within the organization of the enrolled provider.
(2) Overall supervision of the intensive case management unit, as well as individual supervision of intensive case managers, shall be carried out only by mental health professionals. To qualify as a mental health professional under this chapter, an individual shall have at least one of the following:
(i) A master’s degree in social work, psychology, rehabilitation, activity therapies, counseling or education and 3 years mental health direct care experience.
(ii) A bachelor’s degree in sociology, social work, psychology, gerontology, anthropology, political science, history, criminal justice, theology, counseling, education, or be a registered nurse, and 5 years mental health direct care experience, 2 of which shall include supervisory experience.
(iii) A bachelor’s degree in nursing and 3 years mental health direct care experience.
(3) Intensive case managers who are not mental health professionals shall:
(i) Have one of the following:
(A) A bachelor’s degree with major course work in sociology, social work, psychology, gerontology, anthropology, political science, history, criminal justice, theology, nursing, counseling or education.
(B) Be a registered nurse.
(C) A high school diploma and 12 semester credit hours in sociology, social welfare, psychology, gerontology or other social science and 2 years experience in public or private human services with 1 year in direct client contact.
(D) A high school diploma and 5 years of mental health direct care experience in public or private human services with employment as an intensive case management staff person prior to April 1, 1989.
(ii) Be supervised by a mental health professional. A record of supervision shall be on file.
Cross References This section cited in 55 Pa. Code § 5221.3 (relating to definitions).
§ 5221.22. Relationship to other parts of the system.
(a) The intensive case manager shall work closely with the consumer’s mental health therapist or psychiatrist and provide consultation in crisis situations as well as in the overall treatment and management of the consumer’s mental illness, including discharge planning.
(b) The intensive case manager shall be involved in treatment planning for consumers on his caseload who are hospitalized.
(c) The intensive case manager or supervisor shall be present when an involuntary commitment of a consumer on his caseload is being considered to ensure that all appropriate alternatives to hospitalization are considered. When attendance is impossible because of road conditions, emergency situations or other causes, this shall be documented and an effort made to have other informed case managers present or to establish telephone contact.
(d) Enrolled providers shall establish formal and informal links with other service providers as needed to carry out intensive case management activities. Written agreements shall be made with frequently used contacts including the county MH/MR program, psychiatric inpatient facilities, partial hospitalization programs, psychiatric clinics, residential programs, drug and alcohol programs, social and vocational programs and other agencies as needed. For children and their families, linkages shall also be established with child welfare, education, juvenile justice and other child serving agencies.
§ 5221.23. Staffing patterns and limits.
(a) The provider shall have a written policy showing how 24-hour, 7-day per week coverage for intensive case management services is provided. This policy shall be made available to the Department upon request.
(b) The number of cases in a caseload shall be based on the intensity of the need for service but may not exceed 30.
(c) Team assignments to provide intensive case management services are not precluded as long as a single intensive case manager can be held accountable for the services provided to each case.
(d) A supervisor may supervise no more than seven intensive case managers. A supervisor shall maintain a minimum of three contacts one meeting per week with intensive case managers with additional supervision depending upon the performance of the case manager, the activity of the caseload and administrative judgment.
(e) If there are less than seven intensive case managers providing intensive case management, supervisory staff time shall be at least proportionate to the ratio of one full-time supervisor to seven intensive case managers.
(f) Intensive case managers shall be employed as full time staff unless an exception is approved by the county administrator and the area office of mental health.
(1) When a part-time case manager has been approved, the case manager may not provide mental health service except intensive case management to a person on his caseload.
(2) When there is not a sufficient number of eligible persons to constitute a full-time caseload, part-time case management and supervisory staff shall be proportionate to the caseload and supervisory ratios stated in subsections (a), (d) and (e) and organized and operated in a manner that clearly records and identifies time spent on intensive case management.
(g) During the absence or illness of an intensive case manager, the provider shall temporarily designate another intensive case manager to be responsible for every adult or child on the absent intensive case manager’s caseload.
(h) For recordkeeping and billing purposes, services to the child and family members shall be considered together as one case or caseload.
RESPONSIBILITIES
§ 5221.31. Responsibilities of providers.
Intensive case management providers are responsible for:
(1) Assisting the consumer in accessing appropriate mental health services.
(2) Assisting the consumer or the parents, if the consumer is a child, in obtaining and maintaining basic living needs and skills, such as housing, food, medical care, recreation, education and employment.
(3) Assuring the consumer or the parents, if the consumer is a child, continuous, 24-hour access to the intensive case management service.
(4) Providing the intensive case management service in accordance with a written, consumer-specific service plan which includes strengths as well as needs and which is goal and outcome oriented. The outcomes, which shall be measured and reviewed at least every 6 months on an individual and systems basis, are:
(i) Independence of living for the adult; or family integration, if the consumer is a child.
(ii) Vocational/educational participation.
(iii) Adequate social supports.
(iv) Reduced hospital lengths of stay or child out-of-home placements.
(5) Providing intensive case management services in the manner set forth in the approved county plan as it is updated.
(6) Providing intensive case management services as needed in the place where the consumer resides or needs the service. Reasonable attempts shall be made to contact the consumer or the parents, if the consumer is a child, at least every 2 weeks. The contact or the attempt to contact shall be documented. If contact with the consumer or a parent cannot be made, then attempts to locate another member of the family, a relative or a friend shall be documented.
(7) Complying with reporting requirements as mandated by the Department using prescribed forms as required under Chapter 4300 (relating to county mental health and mental retardation fiscal manual).
(8) Documenting at least quarterly the functioning level of each consumer.
(9) Requiring county mental health crisis intervention services to contact the on-call intensive case manager when contacted by a consumer or a parent, if the consumer is a child receiving intensive case management services.
(10) Ensuring that intensive case management staff attend State mandated training sessions or make up training.
(11) Ensuring that the principles developed by the Pennsylvania Child and Adolescent Service System Program (CASSP) are followed in providing services for consumers who are children and their families. See Appendix A.
Cross References This section cited in 55 Pa. Code § 5221.33 (relating to intensive case management records—statement of policy).
§ 5221.32. County administrator.
The county administrator shall:
(1) Regularly review and verify that intensive case management is provided under this chapter.
(2) Provide fiscal and program reports as required by the Department under § 4200.32 (relating to powers and duties).
(3) Certify that State matching funds are available for Medicaid compensable services.
§ 5221.33. Intensive case management records—statement of policy.
To satisfy the recordkeeping requirements in § § 5221.31(4) and 5221.41 (relating to responsibilities of providers; and recordkeeping), intensive case management records should contain, at a minimum, the following:
(1) Intake information. The following shall be included:
(i) Identifying information to include the consumer’s name, address, date of birth, social security number and third-party resources.
(ii) Referral Form, to include date, source and reason for referral to intensive case management and DSM III-R, or subsequent revision, diagnosis.
(iii) Verification of eligibility to receive intensive case management, such as past treatment records, psychiatric or psychological evaluation, letter summarizing treatment history, Individual Education Plan (IEP), and the like.
(2) Assessments and evaluations.
(i) The following assessments and evaluations should be made:
(A) Medical history, taken within the past 12 months, or documentation of the intensive case manager’s efforts to assist the consumer in obtaining a physical examination.
(B) Assessment of the consumer’s strengths, needs and interests.
(C) Summaries of hospitalizations, incarcerations or other out-of-home placements while enrolled in intensive case management, including the place and date of admission, the reason for admission, length of stay and discharge plan.
(D) Children only: IEP, school testing—for example, psychological evaluations—guidance counselor reports, and the like, or documentation of the intensive case manager’s efforts to obtain the information if not in the record.
(E) Outcome information required for annual Consolidated Community Reporting System reporting—that is, consumer level of functioning, independence of living and vocational/educational status.
(ii) The following applies to clauses (A), (C) and (D):
(A) If the intensive case management provider is part of a multiple service agency which maintains the assessments and evaluations in clauses (A), (C) and (D) in another file, the information other than that required to establish eligibility for intensive case management does not need to be duplicated for the intensive case management record.
(B) These reports are considered to be part of the intensive case management record, and shall be made available if the intensive case management record is requested.
(3) Written service plan. The initial plan shall:
(i) Be developed within 1 month of registration and reviewed at least every 6 months.
(ii) Reflect documented assessment of the consumer’s strengths and needs.
(iii) Identify specific goals, objectives, responsible persons, time frames for completion and the intensive case manager’s role in relating to the consumer and involved others.
(iv) Be signed by the consumer, the family if the consumer is a child, the intensive case manager, the intensive case management supervisor and others as determined appropriate by the consumer and the intensive case manager. If the signatures cannot be obtained, attempts to obtain them should be documented.
(4) Documentation of services. The following shall be included:
(i) Case notes. The case notes shall:
(A) Be legible.
(B) Verify the necessity for the contact and reflect the goals and objectives of the intensive case management service plan.
(C) Include the date, time and circumstance of contacts, regardless of whether or not a billable service was provided.
(D) Identify the consumer by name or case number on both sides of each page on which there is writing on both sides. The consumer’s name and case number should appear together earlier in the file.
(E) Be dated and signed by the individual providing the service.
(ii) Documentation of referral for other services.
(iii) Encounter forms.
(5) Discharge information. The following shall be included:
(i) A termination summary, including a reason for admission to intensive case management, the services provided, the goals attained, the goals not completed and why and a reason for closure. The summary shall:
(A) Contain the signature of the consumer, the family if the consumer is a child, and involved others, if obtainable, to verify agreement of the termination.
(B) Contain the signature of the county administrator or designee if the consumer (or family, if the consumer is a child) does not consent to the termination.
(iii) A recommended after-care plan.
Source The provisions of this § 5221.33 adopted September 10, 1993, effective upon publication and apply retroactively to August 31, 1993, 23 Pa.B. 4312.
RECORD AND PAYMENT REQUIREMENTS
§ 5221.41. Recordkeeping.
(a) Intensive case management records shall be identified and maintained apart from other service records using forms required by the Department.
(b) Records shall be maintained for a minimum of 4 years.
(c) Written procedures and records shall be kept in accordance with Chapters 1101 and 4300 (relating to general provisions; and county mental health and mental retardation fiscal manual).
(d) Changes in a consumer’s progress, including admission and termination, shall be documented detailing cause and projected effect in the case record. For example, a meeting with a teacher shall indicate why the meeting was arranged and what the case manager hopes to accomplish in serving the consumer.
Cross References This section cited in 55 Pa. Code § 5221.33 (relating to intensive case management records—statement of policy).
§ 5221.42. Payment.
(a) When conditions of this chapter are met and a county plan is approved by the Department, intensive case management paid from county mental health allocations is eligible for 100% State financial participation.
(b) If intensive case management is provided to an adult or child eligible for Medical Assistance coverage and the service qualifies for Federal financial participation, the provider shall bill the Medical Assistance Program in accordance with procedures established by the Department under Chapter 1101 (relating to general provisions).
(c) The non-Federal portion of the fee shall be met using the State portion of program funds as provided for under this chapter.
(d) No eligible adult or child may be denied needed intensive case management merely because the adult or child is ineligible for Federally-reimbursed services. In these circumstances, 100% State funds may be used to provide payment for the necessary service.
(e) Provider staff meetings, recordkeeping activities and other nondirect services are not billable as intensive case management.
(f) The unit of service for billing purposes shall be 1/4 hour of service or portion thereof in which the intensive case manager or intensive case manager supervisor is in face-to-face or telephone contact with the consumer, the consumer’s family or friends, service providers or other essential persons for the purpose of assisting the consumer in meeting his needs.
(1) Staff time spent in necessary travel may be billed as units of services.
(2) When one or more intensive case management staff persons, acting together, make service contact with or for one or more consumers or family members, if the consumer is a child, during a 1/4-hour period, the maximum number of units that may be billed shall equal the number of staff persons involved or the number of cases being served, whichever is smaller.
(g) A fee-for service payment methodology as established in § 1150.62 (relating to payment levels) shall be used to reimburse intensive case management.
(h) The Department will participate in 100% of the approved expenditures for the following components of intensive case management provided under this chapter:
(1) Assessment and understanding of the consumer’s history and present life situation; service planning, based on the consumer’s strengths and desires, to include activities necessary to enable the consumer to function as an integral part of the community.
(2) Informal support network building.
(3) Use of community resources, to include assistance to consumers or the consumers’ parents, if the consumer is a child, in identifying, accessing and learning to use community resources.
(4) Linking with resources.
(5) Monitoring of service delivery.
(6) Aggressive and creative attempts to help the consumer gain access to resources and required services identified in the treatment plan.
(7) Life support and problem resolution, to include direct, active efforts to assist the consumer in gaining access to needed services and entitlements.
§ 5221.43. Quality assurance and utilization review.
The quality of intensive case management shall be ensured by written provider procedures which include periodic staff conferences, required attendance at training programs for staff members and other oversight. Services are subject to review by the Department and appropriate agencies in accordance with § § 1101.71—1101.75 and by authorized agents of the county government.
§ 5221.44. Conflict of interest.
When an agency that provides intensive case management also provides other mental health treatment, rehabilitation or support services, the responsible county administrator shall ensure that the provider agency:
(1) Does not restrict the freedom of choice of the consumer, or parent, if the consumer is a child, of needed services and provider agencies when needed services, including case management, are available.
(2) Fully discloses the fact that the agency is or may be performing other direct services which could be obtained at another agency if the consumer so desires.
(3) Provides each consumer and parent, if the consumer is a child, a listing of mental health treatment, rehabilitation and support services available within a reasonable proximity to the consumer’s home where needed services could be obtained and if the consumer or parent, if the consumer is a child, so desires, the case manager assists the consumer or parent in obtaining those services.
(4) Documents that the information in this section has been reviewed and understood by the consumer or parent, if the consumer is a child.
CONSUMER RIGHTS
§ 5221.51. Consumer participation and freedom of choice.
(a) A consumer or parent, if the consumer is a child, has the right to refuse to participate in intensive case management without prejudice to other parts of his treatment program.
(b) Case management staff shall be assigned with the participation of the person to be served or parents, if the person is a child. When a person needs intensive case management but the person or the parents, if the person is a child, does not wish to participate in the assignment process, the circumstances and efforts to gain participation shall be documented.
(c) Request for assignment or change of an intensive case manager by an adult or the parents of a child shall be made if possible. Requests of this nature and the outcome shall be documented.
(d) The intensive case manager shall continue to provide services to an assigned case unless the consumer or parent, if the consumer is a child, requests a change or the need for services ends.
(e) Consumers may not be terminated from service for nonattendance or noncompliant behavior that results from mental illness or emotional disorder.
(f) No service decisions may be made in violation of a consumer’s civil rights.
(g) When it is necessary to terminate a consumer from intensive case management, the circumstances and rationale shall be fully documented and approved by the county administrator prior to termination.
(h) The parent with whom a child is living shall act on behalf of the child in service planning. The child shall be encouraged to participate in the process insofar as the child is able and insofar as participation is age and functionally appropriate.
(i) Persons readmitted to intensive case management shall be assigned to the intensive case manager who had previously assisted the person whenever possible, unless the consumer or parents, if the consumer is a child, object.
(j) A parent may act on behalf of the child in decisions relating to services and shall be involved in decisions involving the formation of, and change in, a service plan.
(k) A child 14 years of age or older may consent to treatment or discharge without the consent of the parent if the child substantially understands the nature of treatment and may sign and release records under section 201 of the Mental Health Procedures Act (50 P. S. § 7201).
(l) If the child 14 years of age or older acts independently, the parents shall be notified and have a right to object.
§ 5221.52. Notice of confidentiality and nondiscrimination.
(a) Adults and children receiving intensive case management services are entitled to confidentiality of records and information as set forth in § § 5100.31—5100.39 (relating to confidentiality of mental health records) and other applicable Federal and State requirements.
(b) Enrolled providers may not discriminate against staff or consumers on the basis of age, race, sex, religion, ethnic origin, economic status or sexual preference, and shall observe applicable State and Federal statutes and regulations.
§ 5221.53. Recipient right of appeal.
(a) Department actions for misutilization or abuse against a staff or consumer receiving intensive case management are subject to the right of appeal in accordance with Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings).
(b) Adults and children who have been terminated from intensive case management services over their objections, or the objection of a parent if the child is 13 years of age or younger, shall have the right to appeal the decision in accordance with procedures as outlined in Mental Retardation Bulletin Number 99-86-01 (a joint Mental Health/Mental Retardation Bulletin: Procedures for Review of Service Eligibility and Termination Decisions) effective January 17, 1986 and subsequent revisions of policy. Copies of the bulletin may be obtained from the county administrator.
APPENDIX A
INTENSIVE CASE MANAGEMENT GUIDELINES
Case management is a service which will assist eligible individuals with mental illness, including children with a serious mental illness or emotional disorder, in gaining access to needed medical, social, educational and other services. Activities undertaken by staff providing case management services shall include:
Linking with services—Assisting the consumer in locating and obtaining services specified in the treatment or services plan, or both, including arranging for the consumer to be established with the appropriate service provider.
Monitoring of service delivery—There shall be an ongoing review and written record of the person’s receipt of, and participation in, services. Contact with the consumer shall be made on a regular basis to determine his opinion on progress, satisfaction with the service or provider, and needed revisions to the treatment plan. Contact with the consumer’s therapist shall be made on a regular basis to determine if the person is progressing on issues identified in the treatment plan and if specific services continue to be needed and appropriate. A process shall be developed for resolution between staff members with levels of appeal to be pursued when there is clinical disagreement on the nature and extent of progress a particular consumer is making. Regular contacts shall be made with other public agencies serving the consumer and with parents, if the consumer is a child.
Gaining access to services—Aggressive and creative attempts are required to help the person gain resources and services identified in the treatment or service plan, or both. This may include home and community visits and other efforts as needed. It does not preclude the consumer’s therapist from accompanying the case manager on these visits. Home and community shall be defined broadly to include field contacts which may take place on the street, at the person’s residence or place of work, psychiatric treatment facilities, rehabilitation programs and other agencies where support or entitlements are available to the recipient. (Medicaid may not be billed for case management services provided to eligible persons in hospitals, SNF, ICF and ICF/MR facilities for which Medicaid is being billed for treatment nor for persons in jail.)
Assessment and service planning—A review of clinical assessment information and a general discussion with the consumer is required regarding unmet needs and plans for the future.
Problem resolution—Active efforts to assist the person in gaining access to needed services and entitlements. Staff shall have easy access to communicate with the county administrator for the purpose of obtaining assistance in resolving issues which prevent a person from receiving needed treatment, rehabilitation and support services. On a systems level, this may include providing information to help plan modifications to existing services or implement new services to meet identified needs and providing information to help plan modifications for accessing resources.
Informal support network building—Contact with the person’s family, not family counseling or therapy, and friends, with the permission and cooperation of the adult person, to enhance the person’s informal support network.
Use of community resources—Assistance to persons in identifying, accessing and learning to use community resources appropriately to meet his daily living needs shall be provided as needed. This may include the use of public transportation, the library, stores and the like. This will be done by making a referral to an appropriate service provider, creating such a resource if it does not already exist, in providing assistance directly to the consumer if no other resources are available to provide instruction.
PENNSYLVANIA CASE MANAGEMENT SERVICES FOR
CHILDREN AND ADOLESCENTS WITH SEVERE
EMOTIONAL DISTURBANCE AND THEIR FAMILIESA. Core Values for the System of Care.
1. The system of care should be child-centered, with the needs of the child and family dictating the types and mix of services provided.
2. The system of care should be community-based, with the focus of services as well as management and decision-making responsibility resting at the community level.
B. Principles of Services for Children & Adolescents in Pennsylvania.
1. Children and adolescents deserve to live and grow in nurturing families.
2. Children and adolescents’ needs for security and permanancy in family relationships should pervade all planning.
3. The family setting should be the first focus for treatment for the child or adolescent. Out-of-home placement should be the last alternative. Young children should not need to be in a State hospital to receive appropriate mental health treatment.
4. Communities should develop a rich array of services for children and their families so that alternatives to out-of-home placement are available, such as home-based services, parent support groups, day treatment facilities, crisis centers and respite care.
5. Parents and the child should participate fully in service planning decisions.
6. The uniqueness and dignity of the child or adolescent and his family should govern service decisions. Individualized service plans should reflect the child or adolescent’s developmental needs which include family, emotional, intellectual, physical and social factors. The older adolescent’s right to risk should be considered. Children and adolescents should not need to be labeled in order to receive necessary services.
7. The community service systems which are involved with the child and family should participate and share placement, program, funding and discharge responsibilities.
8. The primary responsibility for the child or adolescent should remain with the family and community. Pre-placement planning should include a discharge plan.
9. Case management should be provided to each child and family to ensure that multiple services are delivered in a coordinated, time-limited and therapeutic manner which meet the needs of child and family.
10. Each child should have an advocate.
The Pennsylvania Child and Adolescent Service System Program (CASSP) guidelines which follow form the foundation for intensive case management services for children and their families:
1. The major thrust of the case management service shall be the commitment to permanancy planning for each child and adolescent with severe emotional problems.
2. The relationship of the case manager with the family shall be one of a partnership, embodying the concept of ‘‘parents and professionals as partners.’’
3. The process of providing case management services to children and adolescents and their families shall be based on the developmental needs and phases of the children and adolescents as they progress to adulthood.
4. The case manager will first utilize the normalizing community services as resources in serving the child and family rather than ‘‘specialty services.’’
5. The case management services shall be delivered in the context of a systems approach, recognizing that case management services shall be integrated with the other child-serving agencies and systems serving the child.
6. The case manager needs to view the family as the primary care giver and recognize the family as the primary resource in the care and treatment of their children.
7. The role of the case manager most often will be that of teacher and consultant to the family.
Cross References This appendix cited in 55 Pa. Code § 5221.31 (relating to responsibilities of providers).
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