210 Case Management Services | HCBS-5300-MANUAL

Georgia Division of Aging Services
Home and Community-Based Services Manual

Chapter:

200

Effective Date:

10/26/2021

Section Title:

Case Management Services

Reviewed or Updated in:

MT 2021-01

Section Number:

210

Previous Update:

MT 2021-01

210.1 Purpose

This chapter establishes the guidelines and requirements for Area Agencies on Aging (AAAs) that provide or contract for the provision of case management services to older adults, persons with disabilities, and their caregivers. These requirements apply to case management services funded fully or partially by funds received through the Division of Aging Services, and DAS suggests their use by agencies providing case management as a fee-for-service enterprise.

Case management provides access for individuals to community resources or assists individuals in identifying and securing resources or services to enhance wellness and remain in the community for as long and as safely as possible.

Case management is a person-centric, collaborative process designed to meet an individual’s complex social and health needs. Through ongoing monitoring and evaluation, case management promotes quality, cost-effective outcomes for the individual and the community.

Case management services must maintain the flexibility to respond to changing needs and preferences of individuals. Therefore, these guidelines seek to enhance the ability of case management to vary service delivery in response to changing individual needs and preferences.

Not every individual who requires long term care services needs or desires case management, and not every individual who can benefit from case management needs long-term care services. Moreover, not every individual who can benefit from case management needs it indefinitely or always requires intensive levels of case management services, (Connecticut Community Care, Inc. (CCCI), p. 11)).

210.2 Definitions

Section moved to MAN 5600, Appendix E, January 1, 2021

210.3 Core Principles

AAAs will ensure that case management services are implemented according to the following Core Principles:

Capacity based: Older persons and persons with disabilities have the capacity for continued growth and autonomy and are the authority on their own needs, know what they need most to achieve well-being, and have abilities, competencies, and resources to help achieve their goals.
Conflict-free: Program staff remains neutral with no interest in the choices made by individuals nor in the types of services or providers selected by the individuals; and to the extent possible, avoids the appearance of conflicts regarding referrals on behalf of individuals.
Culturally Competent: Program staff understands and respects the culture of individuals and interacts with them in ways that are culturally and linguistically competent; and appreciates the ways cultural beliefs and values inform the individual’s acceptance of Service Plan options.
Individualized: Services should focus on meeting the specific needs and preferences of each individual and/or family through joint development, implementation, and review of the Service Plan.
Person-Centered: Program staff approaches individuals and families with empathy and an understanding of their life experiences and challenges by searching for and acting upon what is important to that individual, including their wants, needs, and values.
Professionally Responsible: Program staff maintains the privacy, confidentiality, health, and safety of individuals by adhering to ethical and legal standards and to program guidelines.

210.4A Service Goals

The goals of case management services include:

Maintaining the greatest possible amount of independence and dignity for each person by:
1. Identifying and enhancing the knowledge, skills, and assets of each individual and his/her family and community
2. Enabling individuals to remain in the most appropriate and safest environment they prefer
Ensuring that the right services are provided at the appropriate levels, for the right duration, to the satisfaction of the individual, and at the preferred times to the extent possible, including:
1. Increasing access for individuals to community-based services (regardless of fund source or type of need) by helping individuals navigate the service system, and by providing information and support necessary for individuals to access services
2. Providing an appropriate, comprehensive, and coordinated response to the individual’s needs and abilities, including prevention, maintenance, and restoration of abilities, whenever possible
3. Maximizing community resources by assuring the use of appropriate services through the development of Service Plans that avoid duplication of services
Building and strengthening family and community support by:
1. Improving availability and quality of services
2. Teaching individuals to advocate for themselves through information, education, and support

210.4B Service Outcomes

The desired outcomes of individuals receiving case management services include:

Outcome #1: Older persons and persons with disabilities will experience reduction in risk factors that contribute to out of home placement.

Indicator #1: increased support as measured by Unmet Need score from DON-R
Indicator #2: reduction in intention to place as reported by caregivers, when present
Indicator #3: reduced number of risk factors indicated by periodic reassessments

Outcome #2: Older persons and persons with disabilities will have increased awareness and/or access to services.

Indicator #1: number of services offered/referred/or provided by case management
Indicator #2: number of education activities provided by case management
Indicator #3: reduction in barriers to accessing services indicated by Service Plan documents

DAS does not require that the AAA achieve every outcome and/or indicator for the delivery of case management services to be deemed effective.

210.5 Target Consumer Groups

Because not every individual will desire, accept, or benefit from case management services, it is imperative that AAAs target individuals who can most benefit from community-based case management services and who are at highest risk for institutionalization.

Eligibility criteria for non-Medicaid Home and Community Based case management services include persons who are age 60 and older or who are of any age and have Alzheimer’s Disease or a related disorder, persons with disabilities, and their caregivers.

For the Older Americans Act (OAA) Family Caregiver Support Program, the caregiver is considered a candidate to receive case management support for their own needs. For case management services funded by the Title III-E Family and Caregiver Support Program, the following criteria apply:

An adult, age 18 or older, who provides care for an elderly person, age 60 or older, or who provides care for a person with Alzheimer’s Disease or a related disorder, or
An adult, age 55 or older, who is the grandparent/relative caregiver of a child aged 18 or under or of a disabled person of any age. Children may be related through birth, marriage, or adoption.

ADRC staff should refer clients to case management who have an immediate risk to health and safety and who cannot be adequately served through ADRC interventions. Immediate risk includes, but is not limited to:

Lack of food
Crisis with shelter or environment, including lack of utilities, significant risks related to physical structure, or non-functional essential systems
Crisis with caregiver or support system
Crisis with health, including a prior hospitalization within the last 180 days and a high risk of readmission, and/or
Abuse, neglect, or exploitation

Other appropriate uses of case management services, dependent upon adequate resources, include:

The individual or caregivers desire education and/or assistance in planning for:
- current or future care and support needs of family members who are elderly or who have a disability,
- specific education, counseling, access to resources, or assistance with making plans to support physical, mental, and/or emotional well-being of the individual or the caregiver, or
- specific information about chronic health conditions.
The individual is transitioning from one level of care to another, such as discharge to or from a hospital, rehabilitation facility or nursing home or other level of care.
Complex cases as defined in MAN 5300 CH 202.4E.

The following conditions or situations may suggest that case management services may not be appropriate:

Individual need is not indicated based on individual assessment results including but not limited to: DON-R, NSI, Food Security, and caregiver screening
The individual does not present as being at high risk for institutionalization, or
The individual does not wish to receive case management services.

210.6 Case Management Model

Case management uses the bio-psycho-social-cultural model of assessment that examines the interplay of the client’s functional status and environment.

Case management uses a strengths-based or capacity-based philosophy to service delivery that includes the following components in contrast to a needs-based approach:

Engagement – an unstructured conversational approach vs. structured interview
Strengths Inventory – assesses strengths, abilities, and accomplishments of the individual and the priorities identified by the client vs. traditional needs-based assessment
Personal Goal Planning – the client sets goals, and the Service Plan is developed collaboratively vs. goals driven by case manager
Resource Acquisition – the enhancement of the client’s ability to identify and/or access a wide array of formal and informal services vs. service brokering
Continuing Collaboration – the evaluation of goals and tasks is a collaborative effort vs. an approach based on monitoring or review
Graduated disengagement – an approach that begins with the initial interaction and occurs gradually as the client learns negotiation skills and their support system expands, thus phasing out the need for formal case management vs. service termination

Case management should identify and present to the individual opportunities for intervention in situations that reduce quality of life and potentially reduce the client’s ability to remain in the community, including:

Improper use of services, including duplication of services
Under-use of services
Premature discharge from an appropriate level of care
Inappropriate use of health resources (for example, using emergency room services instead of a primary care physician or health clinic)
Lack of education about chronic conditions or disease processes
Permanent or temporary changes in functioning that may require medical or other evaluation
Use of ineffective services or treatments
Unstable or deteriorating support system
Inability to self-manage health and/or personal affairs

210.7 Access to Services

The AAA will coordinate the provision of case management services with the ADRC program and will develop and implement protocols that facilitate appropriate and timely referrals from ADRC and that initiate case management services in a timely manner.

Not every applicant for services will request, require, or benefit from case management services. Each AAA will clearly identify in its Area Plan how it will coordinate services with ADRC and how it will allocate and manage resources to optimize the effectiveness and efficiency of case management services.

210.8A Core Functions of Case Management

An optimal case management program requires case management staff who have specialized skills and competencies to provide the following core functions:

Assessment
Service Plan Development
Service Plan Coordination
Advocacy
Reassessment
Discharge

Each core function is described in more detail below.

An associated, but equally important, function of case management includes providing education to the client and/or caregiver about a range of topics including health and wellness, personal safety, home safety, accessing the service delivery network, and disease progression.

210.8B Allowable Activities

The AAA may report the following activities in its reimbursement for case management services:

Assessment
Periodic Reassessment
Service Plan Development and Coordination
Follow up by telephone, email, or in person with clients and caregivers, when appropriate and necessary, in accordance with program and service requirements
Coordination with other programs and advocacy on behalf of individuals who require assistance in accessing other systems of care
Documentation, data collection, data entry, and programmatic reporting

Travel to and from the homes of applicants/clients for the purpose of assessment or reassessment may not be billed as units. However, travel is a cost of performing this service and should be included in unit cost calculations.

210.9A Assessment

Assessment occurs over time and seeks to identify the client’s perception of his/her need.

The goal of assessment is to discover the individuals’ interests, needs, assets, and abilities leading to a Service Plan that will capitalize on remaining strengths and compensate for deficits. In addition to information obtained during the assessment, Case Managers must use their experience, expertise, observations, and judgment to determine the individual’s need for services, supports, and resources.

The CMA will ensure that case managers use instruments and tools specified by DAS to appraise clients’ status and needs, and that case managers are proficient in their use. To the extent possible, DAS will provide assessment tools that are evidence-based or validated to maximize the effectiveness and efficacy of the assessment process.

Not all individuals will require the use of every tool; however, the core instruments are required for all individuals. Case Managers will use optional specialized instruments based on the identification of possible areas of concern or need.

MAN 5300 114 Guidelines for Client Assessment describes these assessment domains and specific assessment tools.

Assessment helps the case manager determine whether collateral information is needed and, if so, from whom they should obtain the information. Instances in which collateral information may be needed include, but are not limited to:

The individual seems to be withholding information
The observable function does not match self-reported function
There is suspected cognitive impairment

210.9B Service Plan Development

The plan defines how the Case Manager will measure the success of the intervention(s) and provides a basis for the AAA to evaluate the effectiveness of the Case Manager and for the purchase of or referral to services.

The Case Manager facilitates the client setting goals and establishing a person-centered plan of action necessary to meet the client’s goals. The Case Manager may assign action steps needed to reach these goals to the individual, the case manager, and/or various formal and informal support entities. Public-funded services are intended only as activities to support the client’s personal goals.

Service Planning is intended to empower individuals toward self-efficacy and self-advocacy, therefore minimizing dependence on case management services and the publicly funded services network, whenever feasible. The Service Plan must emphasize the strengths or capacities of the individual, including his/her support system. The Level of Risk and the specific areas of risk identified during the assessment and the client’s personal goals drive development of the Service Plan.

Activities of the Service Planning process include:

Monitoring progress on client’s goals and the Service Plan
Identifying gaps and barriers to the client to enhance outcomes for current and future clients
Advocating on behalf of clients to maximize personal outcomes
Assisting the client to access needed services, including providing referrals and brokering services
Reassessing client needs and the Service Plan periodically
Modifying the Service Plan and the use of service providers as necessary

The Service Plan is the key to the provision of home and community-based services through the public-funded Aging services network. The Service Plan should clearly articulate the duration and level of formal services and the Case Manager should ensure that individuals understand that future service levels are contingent upon periodic reassessments and Service Plan revisions.

Service Plan Development – the Case Manager will utilize the following guidelines in developing the individualized Service Plan for everyone:

Develop and document Service Plans according to DAS specifications and will use assessment data as the basis for planning effective interventions.
Use a multi-disciplinary and holistic approach to care including obtaining input from other professionals involved in the care of the individual including health care providers, registered dieticians, dentists, pharmacists, rehabilitation therapists, mental health professionals, etc., when possible and appropriate.
Clearly link services to be provided with the Level of Impairments and Unmet Needs for Care from the DON-R, with other instruments used in assessing the client and/or caregiver, and link clearly to identified risks.
Complete the initial Service Plan developed with the individual within five business days of the in-home assessment unless a reasonable exception is documented in the client’s record. The Case Manager will document the agreement of the individual and/or the authorized representative to the Service Plan and mail or otherwise provide a copy of the plan to the individual within five business days of completing it.
The Service Plan will include at a minimum:
- The problem or need for assistance as identified by the individual
- The needs identified by the assessment
- The types of services/activities to be provided and the resources to be used, including assistance provided by family, friends, payer sources, or volunteers
- The expected days, times, frequency, and duration of the services or activities
- Long-term and short-term goals, from both a person-centered and safety perspective, as appropriate
- Time frame for follow up and evaluation
- Collaborative approaches to be used
- Anticipated outcomes
The Case Manager will ensure that appropriate formal service providers engaged in the client’s care receive a copy of the Service Plan. The individual may authorize other persons or entities to receive a copy of the Service Plan.

The assignment of Service Plan activities is a key component of the process. DAS recommends the following tiered level of assignment:

The Case Manager assigns as many tasks to the individual as possible, considering the individual’s resources and capacities. This approach is the most effective because it builds on the client’s capacities and builds future problem-solving skills.
The Case Manager assigns as many shared tasks as possible. Tasks may be shared between or among the client and his/her support system or may be shared with the Case Manager. In this situation, coaching by the Case Manager may have long-term benefits for the client.
The Case Manager performs tasks that the client or family is unable to perform. This level should trigger assessment of the capacity and willingness of the client for active involvement.

The Case Manager may use the optional Case Management Action Plan to provide specific individuals involved in Service Plan activities a more user-friendly option than the Service Plan document.

See Appendix 210-D for instructions on how to use the Service Plan documents.

210.9C Care Plan Coordination

Case Managers should ensure that the Service Plan is successfully implemented and that services are effectively coordinated to achieve the greatest impact on behalf of the individual and to maximize the use of community resources. (Note: Service Plan and Care Plan are often used interchangeably)

The case manager should coordinate the Service Plan in a manner that maximizes the independence and choice of the individual while ensuring interventions are the least intensive, least intrusive, most cost-effective, and of the highest possible quality. Coordination may refer to the specific Service Plan and/or to the need for further assessment. Service Plan coordination should include the following activities (CCCI, p. 38):

Referral to and negotiating with both formal and informal providers of care
Communicating, with the individual’s written consent, with the formal and informal service providers, health providers, and family about the coordination of the Service Plan
Empowering the individual and his/her informal caregivers by teaching them how to maximize their access to and utilization of needed health and social services

Teaching and coaching of individuals and their support network are critical components of Service Plan coordination. Ensuring they have essential information to allow informed choices about a variety of care issues contributes to the successful coordination of the Service Plan.

The Case Manager will maintain regular contact with the individual, family and other informal caregivers, and other service providers to evaluate whether the Service Plan is meeting the needs and goals of the individual, whether formal services are being provided in a manner satisfactory to the individual and are meeting the individual’s needs adequately, and whether problems are resolved promptly and appropriately.

The Case Manager will follow up by telephone with individuals or caregivers at the end of the first sixty (60) days of Service Plan implementation to determine progress toward goals and satisfaction with services.
The Case Manager must always review the Service Plan any time the individual is reassessed but may review the Service Plan at other times based on client need and progress toward meeting goals.
The Case Manager will document all contacts and their substance in the client record.
Monitoring of the Service Plan will include:
1. Evaluating the extent to which action steps and strategies have been achieved and have been successful in meeting the individual’s goal
2. Negotiating with the individual to identify gaps and barriers to action steps and goals not being achieved and to identify strategies to overcome those gaps and barriers
3. Reviewing the quantity and quality of formal services and taking appropriate steps to ensure that substandard care is improved or arranging for alternate service provision.

210.9D Advocacy

The case manager should advocate for clients at the service-delivery, benefits-administration, and policy-making levels. The following activities and principles demonstrate effective advocacy:

Promoting the client’s self-determination, informed and shared decision-making, autonomy, growth, and self-advocacy
Educating other health care and service providers in recognizing and respecting the needs, strengths, and goals of the client
Facilitating client access to necessary and appropriate services while educating the client and family or caregiver about resources availability within the community
Recognizing, preventing, and eliminating disparities in accessing high quality care.

(See Case Management Society of America, “Standards of Practice for Case Management”)

210.9E Reassessment

The Case Manager must conduct formal assessments according to intervals established by the individual’s Service Plan or when a significant change occurs in one or more of the following areas:

Health status
Emergency room visit, hospital admission, or nursing home/rehabilitation admission
Behavioral status
Cognitive status
Emotional status
Functional status
Formal or informal support system
Risk category
Service utilization
Housing/environment status

Whenever completing a reassessment of an individual, the Case Manager must also review the individual’s Service Plan to ensure its continued appropriateness and effectiveness.

210.9F Discharge

Planning for termination of services begins during initial contact with the individual or family. Disengagement occurs gradually as the client learns negotiation and self-help skills and as the formal and informal support systems expand, thus often phasing out the need for formal case management. Throughout the period of service delivery, case management fosters maximum independence and empowerment and minimizes dependence on the case manager.

The AAA may discontinue Case Management at any time by mutual agreement between the individual/caregiver and case manager without affecting the individual’s receipt of support services if such services are still justified. Case management may be discontinued at any time at the request of the individual or the caregiver when acting as authorized representative for the individual. The case manager will coordinate discontinuation of case management services with individuals and agencies providing supportive services. The CMA will develop procedures for supervisory review of pending closures.

The CMA shall discontinue case management services when any of the following conditions exist:

The goals and objectives of the Service Plan have substantially been met and no additional goals or objectives are identified
The individual has moved to a long-term care facility or other community placement for an extended or permanent duration
Another service is more appropriate and case management will be provided (such as EDWP, Veterans’ Assistance Programs, other waiver programs, etc.)
The case manager cannot document reasonable progress toward achievement of Service Plan goals and objectives, or the individual is non-compliant with the Service Plan, or the persistent actions of the individual or the family negate the services provided by the various agencies/individuals involved, AND the case manager has documented attempts to counsel with the individual/family to encourage compliance prior to discontinuing services
The family has developed or strengthened a support system that can provide adequate and acceptable care, and the family and other service providers are informed of how to contact the area ADRC if a future need for case management services arise
The individual, caregiver, or individual’s family threatens service provider staff (including the case manager) or engages in illegal or hostile/threatening activity such that the welfare and safety of service provider staff are in jeopardy AND good faith attempts at corrective action have failed
The individual has relocated outside the service area and any transition assistance has been provided, including coordination with case management staff in the area of relocation
The individual request that case management be discontinued
The individual has deceased

Situations may arise in which the current level of service provision is inadequate to ensure the safety and health of the individual. In such situations, the case manager must be diligent about documenting efforts to educate the individual or family about other community resources including more appropriate levels of care, limitations of current services, and the right of the individual to make informed choices. The case manager should assist wherever possible to ensure a smooth transition from case management services.

Case Managers must comply with MAN 5300, CH 202.18 when discharging clients or reducing levels of service.

210.10 Documentation

See MAN 5300, CH 202.5A and MAN 5300, Appendix B.

210.11 Efficient Use of Resources

Case Management services must balance needs and preferences of individuals with the efficient use of public and private resources. Case managers must continually monitor this aspect of service delivery. At times, individual needs or preferences may conflict with payer requirements. Case managers should attempt to educate all parties to maximize impact and the efficient use of services.

The following activities will assist Case Managers in fulfilling this requirement:

Identify comparative costs of alternative Service Plan options
Calculate private and public costs of services recommended in the Service Plan
Communicate cost information to individuals to facilitate an evaluation of their options
Monitor service expenditures over time

Evaluating the efficient use of resources should also include comparing the relative costs of specific services to the value or impact that the specific service provides to the individual.

210.12 Fee-For-Service Guidelines

Each AAA/CMA is encouraged to offer case management services as a fee-for-service enterprise to enhance the sustainability of the Aging network. In so doing, the AAA must follow requirements of the Older Americans Act and MAN 5600 2025 Fee for Service System Overview and MAN 5600 2028 Private Pay Services.

Case management provided to individuals as a fee-for-service should not differ in quality from service provided to individuals funded through public funds. In establishing its fee for service structure, the AAA/CMA should account for the actual cost of the services, including administrative costs, and consider comparable rates within the service market area.

210.13 Administrative Requirements

Providers of case management services, whether AAA or CMA, must adhere to specific administrative requirements to ensure an effective and efficient service delivery system as described below.

Specifically, the AAA will ensure that the following administrative requirements are addressed in policy and procedures:

Retention and Record Keeping (See MAN 5300 CH 202.5 and MAN 5600 1060 Technology and Data Management)
Confidentiality (See MAN 5300 CH 02.5A, MAN 5600 2053 Confidentiality and MAN 5600 2054 Health Insurance Portability and Accountability Act of 1996 (HIPAA)).
Mandatory Reporting of Elder Abuse (See CH 202.19A)
Ethical and Legal Practice (See CH 202.13)
Appeals and Grievances (See MAN 5300 CH 110 and MAN 5300 CH 202.5D)
Fiscal Management (See MAN 5300 CH 102.14 and MAN 5600 3025 Financial Management)

210.13A Eligible Organizations

AAAs may provide non-Medicaid case management services directly (following OAA guidelines) or may contract services to a qualified CMA. The AAA must ensure objectivity and maximize conflict-free service delivery by separating the assessment of individuals from the delivery of other home and community-based services (see MAN 5300 CH 202.4F “Conflict Free Service Delivery”).

Entities qualifying as contractors of AAAs must demonstrate experience in providing case management services to older adults and provide adequate documentation of fiscal viability prior to contract execution (see MAN 5600 3010 Area Agency on Aging Administration and Operations Overview and MAN 5600 3028 Risk Management). CMAs must meet all requirements for contracting as defined in MAN 5600 3050 Compliance with Contractor Responsibilities and Sanctions.

210.13B Agency Structure

The AAA will ensure that the agency providing case management services implements written policies and procedures that govern all aspects of case management operations, including, but not limited to:

The organizational framework for case management services, including how case management assistance is coordinated with AAA ADRC/Gateway operations and with providers of supportive services, including other care coordination/case management entities
Oversight and internal reporting requirements of the case management program, outside of those established by DAS
Personnel management of case managers and other staff of the case management program
The delivery of case management services, including:
- the role of professional, clinical advisors or consultants in the case management program
- timeframes for providing timely responses to individuals’ or caregivers’ inquiries about case management activities
- protocols for communicating with individuals and/or their caregivers regarding case management recommendations and actions
- any aspects of service delivery required by the AAA that exceed DAS requirements

210.13C Staff Administration and Supervision

The CMA will employ a program director/administrator who is accountable for administering the program according to DAS requirements, overseeing quality improvement activities, and supervising case management personnel.

Depending on the size and structure of the organization, the program administrator may provide direct supervision to case managers or there may be additional levels of staffing for supervisory staff who are not involved in overall organizational administration. The CMA will ensure the availability of clinical supervision either via staffing or via contract.

Supervisory Qualifications - The staff person directly responsible for supervision of case managers must have the following qualifications:

Hold a bachelor’s or higher degree in social work, human services, social services, gerontology, health, nursing, or other closely related field, with a background and experience in gerontology, long-term care, or the delivery of community-based services; or
Be a Registered Nurse, properly licensed in the state of Georgia, with a background and experience in gerontology, long-term care, or the delivery of community-based services; and
Demonstrate relevant experience in the provision of community-based case management services; and
Have a minimum of two years’ experience in the supervision of professional case management and support staff; and
Have no conviction in any jurisdiction of any charge of abuse, neglect or exploitation or convicted of any crime (excluding misdemeanors or traffic violations) that would pose a safety or health risk to clients and their families; and
Demonstrate proficiency in the core competencies referenced in 210.11G.

Supervisory Role and Responsibilities – the role and responsibilities of the administrator/director/supervisor include:

To support and clarify the role of the case manager
To be accessible to case managers on a scheduled and as-needed basis
To provide guidance on decisions requiring judgment, assistance with problem situations, and monitoring/approval of Service Plans (including plans for discharge)
To explain goals, policy, and procedures, and to assist staff in adjusting to changes that occur
To encourage professional development and upgrading of skills through access to training and professional resources
To evaluate performance of case managers based on established criteria that include at a minimum: review of individuals’ records, observations of home visits, supervisory conferences, and measurements of productivity and outcomes

Staff ratio – The maximum staffing ratio is one supervisor for every eight case managers.

Agencies are encouraged to identify qualified case management staff who demonstrate the potential for advancement to the supervisory level, and to include training and other educational opportunities in the employee’s professional development.

210.13D Caseload Management

The CMA will consider the following factors when establishing and managing staff caseloads:

The geographic size of the area covered, taking transportation resources into account
The amount of assistant, clerical, and supervisory support available
The availability of community-based services and resources
The Risk Levels of individuals being served
Target populations served
The extent, if any, of responsibility for and control over funding for service interventions exercised by the case manager in voucher or direct purchase service delivery systems

The following factors often predict high use of case management time and should be considered in managing staff caseloads:

Problematic client behaviors, including mental health issues and/or dementia
Low functional capacity and/or high acuity
Problematic informal support, including mental health issues or unrealistic expectations
Problematic formal services, including unreliable or poorly trained staff

210.13E Staff Qualifications

Professional Staff - Based on the estimated staffing needs for caseload coverage (see §210.11D), the CMA will employ and/or contract with an adequate number of competent and qualified personnel to provide case management services.

Minimum qualifications include:

A bachelor’s or higher degree in social work, social services, gerontology, health, nursing, or closely related field; or
A Registered Nurse or Licensed Practical Nurse, properly licensed in the state of Georgia; and
A background in gerontology, long term care, delivery of community-based services or other related practice; and
At least two years of relevant experience in the provision of community-based case management services; or
An equivalent combination of education and experience in applicable fields; and
Not have been convicted in any jurisdiction of any charge of abuse, neglect or exploitation or convicted of any crime (excluding misdemeanors or traffic violations) that would pose a safety or health risk to clients and their families; and
Be able to demonstrate proficiency in the core competencies referenced in 210.11G.

Any staff who holds professional licensure, whose employing organization recruited for the position based on a candidate having that licensure status will meet licensure requirements based on applicable state statutes; maintain a current license; and practice within the scope of that profession.

The CMA will verify licensing and credentials of licensed or certified personnel upon hire and thereafter no less than every two years and have policies/procedures to prevent or address lapses in licensure or certification.

Paraprofessional Staff – The CMA may employ case management assistants to support the delivery of services to individuals and must identify specific tasks appropriate for a paraprofessional. Qualifications for such staff include:

Associate degree in a field of study related to health and human services; or
High school diploma or G.E.D. combined with experience in aging services or a relevant field of health or human services; and
Not have been convicted in any jurisdiction of any charge of abuse, neglect or exploitation or convicted of any crime (excluding misdemeanors or traffic violations), that would pose a safety or health risk to clients and their families.

210.13F Staff Management and Development

Effective case management is contingent upon proper training in assessment, intervention, and evaluation; knowledge of community resources; continuing training and education; and manageable caseloads that provide time for adequate contact.

Written Job Descriptions – The CMA will develop written job descriptions including statements of qualifications and expected professional competencies for all personnel engaged in case management and will implement a process for performance evaluation that occurs at least annually. See Appendix 210-A Core Competencies for Case Managers.

Orientation – The CMA will ensure that case managers receive orientation in current principles, procedures, and areas of case management, with orientation and in-service training to include at a minimum:

The mission, vision, and values of the agency and the aging network
DAS standards and requirements
Policies and procedures, including the agency’s code of ethics
Client’s Rights and Responsibilities
Characteristics and resources of the communities served
Cultural competency appropriate to the population(s) being served
Overview of the regional and state aging networks, the Older Americans Act, and other statutory authorities
Information about all laws, policies, procedures, and reporting requirements regarding client abuse, neglect, and exploitation that is provided prior to the employee providing direct services
The use of instruments and tools designated by DAS in the assessment of clients and their caregivers
Practice related to safety of case managers in the field
Ethical and legal issues related to case management
The use of required electronic and other systems used for data collection, reporting, and maintenance of individual records

Staff Development - The CMA will encourage and document the ongoing professional development of case management staff. When possible, the CMA will provide support for professional participation through membership in or attendance at meetings of professional case management associations.

Time management – Supervisors will assure that case management staff have built into their work plans time for attending routine meetings and trainings and have protected time for administrative duties including documentation.

210.13G Core Competencies

In addition to the minimum qualifications specified in CH 210.11E, AAAs/CMAs will develop recruitment and candidate selection materials and processes, and job descriptions that incorporate and reflect specific attributes that have been identified in successful case management practitioners. AAAs/CMAs should also use these core competencies as the basis for staff development programs. (See Appendix 210-A Core Competencies for Case Managers)

210.13H Information Systems and Information Management

See MAN 5300, CH 202.8

210.13I Client Records

CMAs will maintain separate files, in a manner specified or approved by the Division, containing all written or electronic documentation pertaining to the services provided for each client served, including the following, at a minimum:

Assessment and reassessment documentation
Identifying information, including the name, address, telephone number of the client/responsible party and the emergency contact
Service Plans
Any material reports from or about the client that relate to the services being provided, including progress notes, medical records obtained on behalf of the client, and problems reported by employees of the provider agency
Communications with family members or responsible parties and any other pertinent communication
All case notes related to activities with or on behalf of the client
The date of the referral and dates of any significant contacts, developments, decisions, or changes in plans
All additional information requested or required by the Division.

210.13J Accessibility and Identification

The CMA will ensure community access to case management services by a telephone system that at a minimum:

Operates via a toll-free or collect telephone line that is available during normal working hours
Provides a mechanism to receive timely callbacks from providers and establishes written procedures for receiving or directing after-hours calls, either in person or by recording
Allows access during reasonable and normal business hours, unless mutually agreed upon
Requires all CMA staff to identify themselves when making or receiving calls by full name, title, and agency name

The CMA will provide appropriate office space to allow case managers to conduct appointments with clients, caregivers, or health professionals in a private, confidential setting. The AAA is responsible for establishing regular business hours for case management services and for assessing the extent to which individuals, including family caregivers, need case management services outside of regular business hours (including weekends and holidays) and shall incorporate into its Area Plan documents specific strategies to expand capacity to meet those needs. The AAA may involve the CMA in the assessment of need and/or development of strategies.

The AAA may negotiate differential unit costs for services provided outside of core agency hours only if the provision of such service results in an increased cost to the agency.

The CMA will furnish adequate identification (ID) to Case Management staff who have direct contact with individuals and caregivers. Each employee must carry the identification and either wear it on his/her person or present it to the individual upon request.

An adequate ID is one that is made of permanent materials and that shows the provider agency name, and the name, title, and photograph of the employee. The provider will issue the ID at the time of employment and require its return from each employee upon termination of employment.

210.13K Standards of Promptness

Case managers will initiate contact with the individual or with the caregiver or other representative when contact with the individual is not possible or appropriate, within two business days of receiving a referral from the ADRC for the purposes of introduction and scheduling the initial home visit.

Case managers will conduct face-to-face assessments of individuals in their places of residence (except as noted below) within ten business days of receiving a referral from the ADRC.

Should service requests involve assessment and service planning for persons due to be discharged from a hospital or nursing facility to his/her home or to the home of a caregiver, the assigned case manager will make every effort to conduct the assessment prior to the discharge. The case manager will conduct a follow-up contact (either by telephone or in person) within 2 business days of the discharge to determine whether services needs are being met. If the individual has been discharged, the case manager will conduct the in-home assessment within two business days of the discharge.

If any standard of promptness cannot be met due to circumstances beyond the case manager’s control, the case manager will document the efforts to achieve compliance in the client’s record/file.

Case managers will conduct face-to-face assessments of individuals in their places of residence (except as noted below) within ten business days of receiving a referral from the ADRC.

If any standard of promptness cannot be met due to circumstances beyond the case manager’s control, the case manager will document the efforts to achieve compliance in the client’s record/file.

210.13M Ethical and Legal Issues

In fulfilling their ethical responsibilities to individuals, case managers will:

Provide services with respect for the autonomy, dignity, privacy, and rights of the individual
Provide information to the individual that supports making informed decisions about their situation and need for assistance
Respect the individual’s right to privacy by sharing only information relevant to his/her care within the requirements of law
Seek appropriate resources and consultation to help formulate ethical decisions

In addition to following guidelines for ethical and legal practice required by MAN 5300 CH 202.13, and the responsibilities described above, case managers must be especially diligent about issues that arise during the practice of case management services, including:

When the case manager’s professional judgment or values conflict with the beliefs, values, or preferences of the individual or the individual’s family
When the individual’s beliefs, values, or opinions about services conflict with those of the caregiver or responsible party
When there is tension among the individual’s preferences, case manager’s judgment, and payer constraints
When the individual’s preferences are at odds with the case manager’s role of managing public or community resources effectively
When conflict is created by the individual’s right to dignity of risk

The CMA should include such information in initial orientation and training and/or in the agency’s ongoing staff development program. The following techniques may be useful in handling ethical concerns:

Involving the individual in goal setting and Service Planning
Providing as much information as possible to the individual to allow for informed consent
Using peer review, Service Planning committees, or clinical supervision to discuss and resolve issues of dignity of risk or allocation of resources
Following HIPAA and other confidentiality guidelines
Using outcome measures to track the type and quantity of services that are appropriate

210.13N Grievances and Appeals

Individuals may appeal recommendations to change, reduce or terminate the delivery of case management services. The case management agency must follow requirements set forth in MAN 5300 110 Grievance Procedures for Individuals in Non-Medicaid HCBS Programs.

210.13O Program Evaluation and Monitoring

Using tools specified by the Division at a minimum, the AAA and DAS will periodically monitor the performance of the CMA to determine the degree to which the CMA accomplished defined program outcomes and objectives and individual client outcomes. The AAA will monitor for compliance with these requirements and evaluate performance on at least an annual basis and shall provide written feedback to the CMA about its findings and will provide technical assistance for continuous quality improvement. If the AAA is the CMA, it will develop and implement a protocol for self-evaluation and objective internal review of case management services.

The AAA must monitor and evaluate the following processes, at a minimum:

Identification and tracking of key quality indicators (see Appendix 210-B, “Quality Improvement Data”)
Review of client records, including assessments, Service Plans, and documentation to measure quality, accuracy, and consistency of records
Review of the degree to which case management serves target populations
Review of compliance with these guidelines
Review of existing program’s operations, including cost-effectiveness of service
Mechanism for internal reporting of quality-related problems
Implementation of corrective action plans for identified problems

References

Case Management Society of America, “Standards of Practice for Case Management.”

National Association of Social Workers, Standards for Social Work Case Management

Division of Aging Services, MAN 5300 CH 114, Guidelines for Client Assessment

Commission for Case Management Certification
CCMC | The Commission for Case Manager Certification

Canadian Core Competency Profile for Case Management Providers

Documentation and Record Keeping: A Guide for Service Providers, National Council of Social Service.

Guidelines for Case Management Practice across the Long-Term Care Continuum. Report supported by grant from The Robert Wood Johnson Foundation, November 1994. Connecticut Community Care, Inc., contractor. (Referenced in text as CCCI)

Center for Aging & Disability Education and Research at Boston University, School of Social Work.

“Clinical Documentation and Recordkeeping” by Hillel Bodek, Chairperson of the Committee on Ethics and Professional Standards and the Committee on Forensic Clinical Social Work New York State Society for Clinical Social Work, Inc.

DAS MAN 5600, Appendix E “Glossary of Terms, Abbreviations and Acronyms”