Initial Assessment: Case managers should conduct an initial assessment for all NMCM clients to determine their need for medical and support services, as well as barriers to accessing services, client strengths, and resources. The 30-day completion time permits the initiation of case management activities to meet immediate needs and allows for a more thorough collection of assessment information.

The assessment should determine client needs in the following areas:

• Access to medical care and medication
• Food security and nutritional services
• Financial needs and entitlements
• Housing security
• Transportation
• Legal assistance
• Linguistic services
• Any other applicable medical or support service needs

Case managers should also include the following in the initial assessment:

• Client strengths and resources
• Other agencies that serve client and household

1. Percentage of clients with a completed initial assessment within 30 calendar days of the first appointment to access NMCM services.

Care Planning: The client and the case manager will actively work together to develop and implement the care plan. Care plans include at a minimum:

• Problem statement based on client need
• One to three current goals
• Interventions to achieve goals (such as tasks, referrals, or service deliveries)
• Individuals responsible for the activity (such as case management staff, the client, other team members, the client’s family, or another support person)
• Anticipated time for the completion of each intervention

Staff should update the care plan with outcomes and revise or amend the plan in response to changes in access to care and services. Case managers should update tasks, types of assistance in accessing services, and services as they identify or complete them, not at set intervals.

Case managers must update care plans at least once every six months, and should document that they reviewed and revised, if appropriate, all required elements (problem statement or need, goals, interventions, responsible party, and timeframe).

2. Percentage of clients with a care plan that contains all of the following:
   1. Problem statement or need;
   2. Goal(s);
   3. Intervention (tasks, referral, service delivery); 2d: Responsible party for the activity; and
   4. Timeframe for completion.
       
3. Percentage of clients with care plans that have been updated at least once every six months.

Assistance in Accessing Services and Follow-Up: Case management staff should work with the client to overcome barriers to accessing services and complete the interventions identified in the care plan. Case managers should base assistance on the needs identified, collaboratively with the client, during the care planning process. If the client denies any assistance, staff should document this.

When clients receive assistance in accessing services outside of the agency providing NMCM, case notes must include documentation of follow-up and outcome.

4. Percentage of clients with documentation of assistance provided, based on the client care plan.
    
5. Percentage of clients who received assistance in accessing outside services that have documentation of follow-up.

Case Closure and Graduation: Agencies should close cases and document in the client’s chart when clients are no longer engaged in active case management services.

This should include brief narrative progress notes, formal case closure, and a graduation summary. The case management supervisor should review and sign all closed cases.

Staff must notify clients of plans for case closure and provide written documentation explaining the reason for closure or graduation and the process clients can follow if they elect to appeal the case closure or graduation from service. At the time of case closure, agencies should also provide clients with detailed information on how to reestablish NMCM services.

A client is “out of care” if three attempts to contact the client (via phone, e-mail, or written correspondence) are unsuccessful and the agency has given the client 30 days from initial contact to respond. Staff should utilize multiple methods of contact (i.e., phone, text, e-mail, or certified letter), as permitted by client authorization, when trying to re-engage a client. The agency should initiate case closure proceedings 30 days following the third attempt at contact.

Common reasons for case closure include:

• The client no longer needs non-medical case management services.
• The provider refers the client to another case management program.
• The client relocates outside of the service area.
• The client chooses to terminate services.
• The client is no longer eligible for services due to not meeting eligibility requirements.
• The client is lost to care or does not engage in service.
• The client is or will be incarcerated for more than 6 months in a correctional facility.
• The provider-initiated termination due to behavioral violations, per agency’s policy and procedures. 

Graduation criteria:;

• The client completed case management goals for increased access to services or care needs.
• The client no longer needs case management services (e.g., client can resolve needs independent of case management assistance or has needs that RHCS can adequately meet.

6. Percentage of closed cases with discharged documentation including:
   1. A formal case closure or graduation summary that documents the reason for case closure;
   2. A supervisor’s signature and approval;
   3. Client notification, including the provision of written documentation explaining the reason for case closure or graduation; and
   4. The provider gives the client information on appealing the case closure and the process to re-establish NMCM in the future.