Case Management Standards of Practice

The case management standards outlined below are to be used in performance of case management service to clients, and in the maintenance of complete and accurate records. Case management activities and observations must be documented in the client record as clearly as possible.

The effective case manager will adhere to these required standards of practice.

I. The case manager will screen each client for case management eligibility;

• within 5 working days of the client's referral for case management services;
• to determine the client's HIV + diagnosis;
• to determine the client's need for case management services by assessing/asking the client if he/she is currently receiving case management services through another source; and
• to determine the client's desire for case management services as expressed by the client or his/her authorized/designated representative.

II. The case manager will explain and help the client to complete an application and the client agreement form to each client or designated representative before services are provided, assuring a clear understanding of:

• the client's right to choose case management services;
• the client's right to utilize an established grievance procedure;
• the client's right to change case management or discontinue case management services at any time;
• the circumstances under which the case management service may be discontinued by the case manager; and
• the client's permission for the case manager to release or obtain information about his/her medical condition or service plan when the information is needed to coordinate services. Such release of information or obtaining of information by the case manager shall remain consistent with Pennsylvania's confidentiality laws including, but not limited to, Act 148.

III. The case manager will perform a comprehensive client needs assessment:

• within 30 days of the client's screening for and consent to receive case management services;
• identify the client's strengths, resources, needs and problems:
• utilizing medical, social service, and housing information about the client; and
• confirmation of HIV+ status for services, if applicable;
• based on a client interview, which is conducted at a mutually acceptable location, preferably their residence, but including a home visit at a mutually agreeable time.

IV. The case manager will develop an individual Service Coordination Plan (SCP):

• within 30 days of the client's screening for and consent to receive case management services;
• within the participation of the client and/or his or her designated representative;
• which includes realistic, measurable, and mutually acceptable goals;
• which identifies the action(s) needed to achieve each goal, including the actual or potential provider;
• which specifies the goal for each action (including target date for accomplishment);
• which specifies actions for which the client and/or the designated representative is responsible;
• when indicates the result of each service and/or action step; and
• which incorporates cost effective services when available.

V. The case manager will maintain documentation for each client which includes:

• the case manager's name;
• the client's name and/or unique identifier number:
• the time, date, place, and a description of each case management service; and
• information relating to the services provided which further reflect progress toward reach goals identified in the SCP. Such documentation should be provided in a format such as Data/Assessment/Plan notes (or DAP notes).

VI. The case manager (together with the client, and designated representative) will reassess each client's needs:

• at least every 90 days, in a face to face contact, consistent with the client needs;
• noting the progress toward goal achievement;
• noting the effectiveness of the services and the SCP; and
• indicating in the SCP any changes, additions, or deletions to current services including the need for continued contact and for case management services.

VII. The case manager will review the SCP:

• when there is a change in client status;
• when services are added or deleted; and
• after each re-assessment.
• evaluating need for changes.

VIII. The case manager will identify problems or critical issues that may hinder services taking timely action to resolve them (client advocacy).

Discharge from case management services:

IX. If the case manager encounters any change in the client's condition or circumstances that may warrant discharge from case management services he/she will notify the client and designated representative, without delay, in order to make timely alternative arrangements.

Continuity of services-termination of services:

X. The case manager will provide appropriate coordination efforts to assure continuity of appropriate services, but will terminate a client from Ryan White eligible case management services in the following circumstances;

• when one year has lapsed since the client last needed contact or service from the case manager:
• when the client moves to a new service area;
• when the client becomes eligible for, and when services are transferred to, a Medicaid funded case manager;
• when the client is hospitalized, in jail, or locate in some institutional setting whereby case management services are unnecessary or provided within the institutional setting;
• when the client chooses to terminate service with the agency.