7004 TERF Case Management | APS-5500-MANUAL
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Georgia Division of Aging Services |
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Chapter: |
7000 TERF Case Management |
Effective Date: |
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Section Title: |
TERF Case Management |
Reviewed or Updated in: |
MT 2021-01 |
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Section Number: |
7004 |
Previous Update: |
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Summary Statement
The overall goal of Temporary Emergency Respite Fund (TERF) Case Management is to support victim of vulnerable adult abuse as they work to transition from an environment of abuse, neglect or exploitation at the hands of their caregivers into a safe, stable and supportive setting through the extension of transitional housing and development of case management services.
Basic Considerations
The purpose of TERF Case Management Services is to:
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assure the client gains access to their own assets within at least 30 days of placement
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assure that all benefits for which the client qualifies have been applied for within 30 days of placement
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procure stable housing that will meet the needs of the client within 30 days of placement
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minimize the number of times the vulnerable adult move after the initial placement
Procedures
Once the client has been evaluated and is in need of Case Management Services, a dialog will be held with the client to discuss service needs and options. The TERF Supervisor or “Designee” will assign the client to a TERF Case Manager who will develop a case services plan with the client.
Initial Evaluation
The TERF Case Manager, once assigned, will:
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complete a face-to-face visit with the client within 2 business days;
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Assess and identify the level of care needed to meet the needs of the client;
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determine the client’s monthly income and financial resources;
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identify the permanent living situation client desires. If applicable, determine if Personal Care Home (PCH) can be a long-term placement;
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Discuss needs, strengths and goals for initial case services plan;
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Determine if placement assistance is needed beyond the initial 7-day TERF placement; and
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Determine if client has financial resources to provide for his/her apparel, personal effects and incidentals at current placement. (Refer to Chapter 9075 in MAN 5600 regarding apparel, personal effects and incidentals covered during initial TERF placement)
Case Management Services – 30 Days of Assignment
The TERF Case Manager, after the initial face-to- face visit and within 30 days, will:
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Verify the client’s income and financial resources; determine whether or not those resources are secure and not accessible by the alleged perpetrator;
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Determine if preferred permanent living situation and/or services needed to meet the client’s needs can be secured using the client’s financial resources; determine if additional financial resources client is eligible for and/or charitable contributions are needed;
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Create goals and steps for case service plan with dates of expected completion of each step and goal. Discuss with the client to obtain agreement and make modifications as needed;
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Locate stable housing that meet the client’s needs and are within the client’s financial means;
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Apply for services and resources that the client is eligible for (Refer to Chapter 5 in MAN 5500 regarding statewide resources);
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Follow-up with the client after resources, services and placement are established to verify appropriateness of services provided.
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Determine if the client is in need of any additional supports or services;
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Update the TERF Supervisor weekly regarding procurement of needed services and implementation of case services plan to allow for modification of services and case plan prior to 30-day time frame;
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Plan for case closure once the client has secured and established permanent placement and/or services; and
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Document discussions and achievements of the case plan goals with the client, and with any others that might have knowledge or otherwise be participating in the case plan within the DAS Data System (DDS).
Case Management Services – After 30 Days of Assignment
If the TERF Case Manager and/or client is unable to meet any of the goals and steps within the case plan within 30 days and the vulnerable client continues to need case management, the TERF Case Manager will:
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Confer with the TERF Supervisor no later than 5 days prior to the 30th dayregarding obstacles/hindrances preventing the client from retaining permanent living environment or services needed to meet their needs.
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Determine the need of Emergency Relocation Fund (ERF) if the client is without financial resources to continue residing in temporary placement and securing personal effects and incidents (Refer to Chapter 9080 in MAN 5600 regarding Utilization of ERF);
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Follow up on applications for services and resources to determine status and, if applicable, when services and/or placement will be available for the client’s use;
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Discuss with the client application status, new services and/or housing to be applied for to meet/achieve services goals. Modify service case plan as needed;
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Follow-up with the client after resources, services and placement has been established to verify appropriateness of services provided. Determine if the client is in need of any additional supports or services;
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Plan for case closure once the client has secured and established permanent placement and/or services; and
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Maintain documentation in DDS and detail efforts regarding securing safe permanent placement and/or services for the client.
Termination
The TERF Case Management services shall be terminated when the client:
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obtains permanent housing and/or services needed to live safely in the setting of their choosing;
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fails to meet the criteria for TERF case management services:
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is placed under the guardianship of the Department of Human Services;
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when the client’s whereabouts are unknown, due to leaving temporary placement and refusing to communicate with TERF Case Management team and attempts to locate the client is not successful; or
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the client expresses that he/she no longer desires TERF Case Management services and the client has capacity to make decisions.
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When TERF Case Management determines that a disabled adult or elder person in need of protection and cannot remain protected due to an incapacity and there are not sufficient alternatives to guardianship or conservatorship, a petition for the appointment of a guardian and/or conservator can be filed with a probate court pursuant to the Disabled Adults and Elder Persons Protection Act (O.C.G.A. § 30-5-5).
The TERF Case Manager will follow the “Evaluating Cognitive Capacity” and Evaluating Level of Risk” procedures as determined MAN5500, Section 3009.
When possible, the TERF Case Manager will request an evaluation from a medical and/or health provider to assess the client’s capacity to consent.
The TERF Case Manager will staff the case with the TERF Supervisor to determine next steps. The TERF Unit will attempt to identify relatives to obtain guardianship are available that will safeguard the client in an environment where the client’s needs are met. If those alternatives are available, the TERF Supervisor will provide next steps to take.
If there are no alternative guardians available, the TERF Supervisor will staff the case with the Program Manager to determine if the case is eligible for a guardianship staffing. The Program Manager will coordinate a Guardianship Staffing to include TERF Case Manager, TERF Supervisor, Public Guardianship Office Section Manager or Designee and DHS Associate General Counsel.
Feedback will be provided but is not limited to:
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Alternatives to guardianship not previously considered;
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Additional methods for seeking out family and friends willing to assume guardianship;
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Limitation of Guardianship to resolve or mitigate presenting risk; or
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Request for a multidisciplinary meeting.
When a decision has been made to move forward with the Guardianship, the DHS Associate General Counsel will contact the local SAAG (Special Assistant Attorney General) to file the petition on behalf of the Department.
Additional information regarding Petition Writing, Petition Filing and appointment of DHS Guardianship can be located in MAN5500, Section 3009.