Non-Medical Case Management

Initial Assessment: All clients enrolled in NMCM should receive an initial assessment to determine their need for medical and support services, as well as barriers to accessing services and 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

The following should also be included in the initial assessment:

• Client strengths and resources
• Other agencies that serve client and household
• A brief narrative summary of the assessment session(s)

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 other support person)
• Anticipated time for the completion of each intervention

The care plan should be updated with outcomes and revised or amended in response to changes in access to care and services. Tasks, types of assistance in accessing services, and services should be updated as they are identified or completed, and not at set intervals.

Care plans must be updated at least every 6 months, with documentation that all required elements (problem statement/need, goals, interventions, responsible party, and timeframe) have been reviewed and, if appropriate, revised.

2. Percentage of clients with a care plan that contains all of the following:
    
   1. Problem statement/need
   2. Goal(s)
   3. Intervention (tasks, referral, service delivery)
   4. Responsible party for the activity
   5. Timeframe for completion
       
3. Percentage of clients with care plans that have been updated at least every 6 months.

Assistance in Accessing Services and Follow-Up: Case management staff should work with the client to overcome barriers to accessing services and to complete the interventions identified in the care plan. Assistance should be based on the needs identified, collaboratively with the client, during the care planning process.  If any assistance is denied by the client, this should be documented.

When clients are aided with services elsewhere (outside of the agency providing NMCM services), case notes 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 with documentation of any assistance denied by the client.
    
6. Percentage of clients who received assistance in accessing outside services that have documentation of follow-up.

Case Closure/Graduation:  Clients who are no longer engaged in active medical case management services should have their cases closed with a case closure summary documented in the client’s chart. This should include both a brief narrative progress note and formal case closure/graduation summary. All closed cases should be reviewed and signed by the case management supervisor.

Clients must be notified of plans for case closure and provided written documentation explaining the reason for closure/graduation and the process to be followed if the client elects to appeal the case closure/graduation from service. At the time of case closure, clients should also be provided with contact information to reestablish NMCM services and information on the process for reestablishment.

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

Common reasons for case closure include:

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

 Graduation criteria:

• Client completed case management goals for increased access to services/care needs
• Client is no longer in need of case management services (e.g., client can resolve needs independent of case management assistance or has needs that can be adequately met by RHCS) 

Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of case closure or graduation, unless the case is being closed due to a deceased client.

7. Percentage of closed cases that include documentation stating the reason for closure and a closure summary (brief narrative in progress notes and formal case closure/graduation summary).
    
8. Percentage of closed cases with documentation of supervisor signature/approval on closure summary (electronic review is acceptable).
    
9. Percentage of clients with closed cases who were provided with information about the reason for discharge, the process to appeal their discharge, and how to reestablish NMCM services.