3032 Case Planning

Georgia State Seal

Georgia Division of Aging Services
Public Guardianship for Adults Manual

Chapter:

3000 Case Management

Effective Date:

06/30/2023

Section Title:

Case Planning

Reviewed or Updated in:

MT 2023-03

Section Number:

3032

Previous Update:

MT 2023-01

Summary Statement

All Department of Human Services (DHS) adult guardianship cases shall have a case plan developed and implemented based on the information obtained from documentation and assessments. The case plan must specify goals and actions to address the person under guardianship’s medical, social, vocational, educational, transportation and other service needs. Public Guardianship Office (PGO) staff shall monitor the case plan at least monthly and update it as needed.

A guardian shall give any consents or approvals that may be necessary for medical or other professional care, counsel, treatment, or service for the ward. The guardian shall exercise granted powers reasonably necessary to provide adequately for the support, care, education, health, and welfare of the ward/person under guardianship O.C.G.A. § 29-4-23.

Case Planning addresses the document collection and required assessments needed for the Case Plan as well as the development, completion, review and updating of the Case Plan by the Case manager (CM).

Basic Requirements

Documentation Collection

Information and documentation used in developing the case plan include but are not limited to:

  • Client interview

  • Client history

  • Information from knowledgeable sources such as family members, medical providers, social workers, and educators

Assessments

Required

  • Client Assessment:

    The Client Assessment provides a summarized history introducing the client. A Client Assessment must be initiated in the Division of Aging Services (DAS) Data System (DDS) within 10 days after contact and completed no later than 30 calendar days after assignment. For temporary guardianships, the due date will be determined by the length of the guardianship itself. The assessment is a living document to which information must be added as it becomes available. The Client Assessment Includes:

    • Client demographics and domicile

    • Legal information

    • Current services

    • Medical information

    • Education and vocational information

    • Social and recreational preferences and activities

    • Religious/spiritual preferences and beliefs

    • End of life arrangements

  • Determination of Need – Revised (DON-R)

    The DON-R is used to help determine a person’s functional capacity and level of impairment and their unmet need for assistance in dealing with these impairments. It assesses both impairment in functioning on (Basic) Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) which are essential to evaluating whether a person can live independently in the community. A DON-R must be initiated in the Division of Aging Services (DAS) Data System (DDS) within 10 days after contact and completed no later than 30 calendar days after assignment.

    ADLs include:

    • Eating

    • Bathing

    • Grooming

    • Dressing

    • Transferring in and out of bed/chair

    • Bowel/bladder continence

    IADLs include:

    • Managing money

    • Telephoning

    • Preparing meals

    • Laundry

    • Housework

    • Activities outside the home

    • Routine health care activities and management

    • Special health care activities and management

    • Being alone

    The DON-R measures only functional ability to perform essential components, not the client’s willingness to do the function or his/her desire for assistance (or lack thereof). The Level of Impairment (LOI) must reflect the extent to which the client can/cannot perform the essential components and the reason the client cannot perform the essential components (do not list diagnoses). The level of Unmet Need (UN) must reflect the extent to which the need identified in LOI is not met and the degree of risk to health/safety if the need remains unmet.

Optional

Any other available assessment, such as the Saint Louis University Mental Status (SLUMS) examination, that addresses the person under guardianship’s strengths, limitations, needs, preferences and wishes shall be used in developing the case plan.

Case Plan Development

For permanent guardianships, an initial Case Plan must be completed in DDS within 30 calendar days of case assignment for permanent and successor guardianships. Case plans are not required for temporary guardianships.

The guardianship case plan covers all areas of life of the person under guardianship for which a guardian may have duties. They are:

  • Guardianship

  • Income/Financial

  • Medical/Health

  • Mental/Emotional

  • Housing/Shelter

  • Rights/Legal

  • Basic Necessities/Personal Possessions

  • Social/Relational/Sexual

  • Recreational

  • Educational/Vocational

  • Spiritual/Religious/Moral

  • Dying/End of Life

When developing the case plan, it must be person-centered and focus on the client’s needs, strengths, and desires as well as their weaknesses, risks, and challenges. It must not:

  • Contain generic goals

  • Recite standard PGO case management duties or requirements

  • Focus on the provider or the provider services over the person and their service needs

The case plan shall include the following:

  • Outcomes/Preferences

    Outcomes/preferences are a combination of the things the person under guardianship would like for his or her life and things that are not important to the person but are critical for the guardianship. Outcomes must be generated with the person under guardianship, not just for the person under guardianship.

  • Goals

    The plan goal is a statement of desired targets to achieve the outcome identified. PGO case plan goals should be “SMART” goals (Specific, Measurable, Achievable/Actionable, Relevant, Time-bound). Goals must take into consideration:

    • Strengths or resources

    • Favorable factors that can help meet the goals of the care plan

    • Risks or challenges that could prevent meeting the goals of the care plan

  • Action Steps

    Actions Steps documents specific activities and responsibilities for the guardian, the person under guardianship, providers, facilities, family members, friends, etc., to reach the desired goal. Action Steps provides concrete proof of notice or responsibility.

    Actions steps define the who, what, and when of meeting the planned goals.

    • Who? Each step shall be assigned to someone.

    • What? Each step must state what will be done in clear detail, whereas each person knows what is required of them.

    • When? Each step must specify a duration and/or a deadline for completion.

Monitoring and Follow-up

Monitoring and follow-up activities are necessary to ensure the case plan is effectively implemented and meets the client’s need. As service monitor, the DHS guardian representative has an affirmative responsibility to investigate every service received and to determine, amongst other things:

  • The purpose of the service

  • The qualifications of the staff providing the service

  • How the staff providing the service treat people receiving the service

The case plan is reviewed monthly and updated if needed. The Case Plan helps drive scheduling of monthly contacts and case documentation each month. Contact may be with the individual, family members, providers, or other entities.

During contacts, review whether:

  • Services are being furnished in accordance with the case plan

  • Services in the case plan are adequate

  • Are changes needed to meet or address the person’s needs or changes in the person’s circumstances.

Case Plan Updates

Updated Case Plan: When a drastic change in the person’s life occurs (such as onset of a serious illness, having a massive stroke, or change in physical abilities), such that the person’s capacities, strengths, needs, opportunities, or physical or behavioral health have changed significantly, a new case plan is required. It is called an “additional” case plan.

Annual case plan: An annual update to the case plan is due no later than 30 calendar days after the anniversary of the guardianship appointment.

Case Plan Signatures and Copies

The client must sign the case plan (if able) and be given a copy. Each person who owns an action item shall be asked to sign the case plan and be given get a copy of their action steps with confidential information redacted. The CM must attach copies of signed case plans to the Case Plan note in DDS.

References

O.C.G.A. § 29-4-23 et seq.; MAN 5800, Section 3060