CASE MANAGEMENT: THEN AND NOW

1. CASE MANAGEMENT: THEN AND NOW

2. BDAP DEFINES CASE MANAGEMENT AS: A collaborative process between the client and the case manager that facilitates the access to available resources and retention in treatment and support services, while simultaneously educating the client in the skills necessary to achieve and maintain self-sufficiency and recovery from substance abuse disorders.

3. TWO PRIMARY GOALS OF CASE MANAGEMENT 1. To increase client retention in and completion of treatment in order to move clients toward recovery and self-sufficiency and, 2. To increase client access to core services such as primary health care, psychiatric care, stable and secure living environment, positive support networks, vocational training, and employment.

4. CASE MANAGEMENT REDEFINED PER THE MAY 16TH LETTER • One individual is permitted to perform screening, assessment and intensive case management. • 257.4 covers screening, assessment, and intensive case management.

5. MANDATED CASE MANAGEMENT FUNCTIONS: 1. Screening 2. Assessment 3. Intensive Case Management (ICM)

6. SCREENING DEFINITION Screening is specifically defined as the determination of the need for a referral to emergent care services.

7. SCREENING • Given that screening is often the most critical contact with a client, lack of skill and proper training may render the screener incapable of obtaining needed information which may lead to inappropriate decisions regarding the need for care and may also prevent the client from following through with recommendations. • The SCA must develop a screening policy that includes: • Who conducts screening at all points of entry; • Required training and education; • Required screening tool components; and, • Referral protocols to address emergent care needs.

8. THREE SCREENING OPTIONS • Due to differences in service delivery systems, BDAP allows screening to be conducted in the following three ways: • Option 1: Skilled Medical/Human Service Professional; • Option 2: Skilled Medical/Human Service Professional in conjunction with support staff; or

9. THREE SCREENING OPTIONScontinued • Option 3: Support staff with the appropriate documented education, training and/or experience in the following areas: • Psychiatric • Perinatal/Prenatal • Detoxification

10. SCREENING TOOL If the SCA or its sub-contractors choose to develop their own screening tool, the tool must include areas to gather the following information: 1) date of initial contact; 2) date of Level of Care Assessment; 3) if necessary, an explanation of why the time frame for an assessment was not met must be documented; 4) questions to determine the need for emergent care; and

11. SCREENING TOOL continued 5)When the SCA chooses the second option of screening, the screening tool must include trigger questions. The SCA shall use the provider monitoring tool to ensure that all providers sub-contracted to perform screenings are using screening tools which include the information on the preceding slide.

12. ASSESSMENT ACTIVITIES • The function of assessment includes a number of activities that may be done by the SCA’s Case Manager and/or by the SCA’s sub-contracted assessment providers. • The SCA has discretion in determining whether SCA staff and/or sub-contracted staff provide the following assessment activities: 1) Level of Care Assessment and Placement Determination; 2) Level of Case Management Determination; 3) Continued Stay Review; and, 4) Client Liability Determination

13. ASSESSMENT POLICY • The SCA must have a written policy that includes: • Who conducts LOC assessments; • Required documentation; • LOC assessment tool; • Confidentiality, including use of consent forms; • Timeframes; and, • Waiting list protocols.

14. ASSESSMENT TOOL • When conducting Level of Care Assessments for adults, the SCA may use the BDAP-approved assessment tool. This tool has been designed to crosswalk with the six dimensions of the Pennsylvania Client Placement Criteria (PCPC) and contains sections to gather information pertaining to any special needs the client may have that pose as potential barriers to treatment. • In order to determine the need for a referral for ICM services, the tool also corresponds with the Inventory of Support Services (ISS).

15. ASSESSMENT TOOL COMPONENTS • If the SCA or its’ sub-contracted providers choose to use a different assessment tool, the SCA shall ensure that the tool includes questions in the following areas: 1) Date of Initial Contact & Date of Assessment 2) Demographics 3) Education 4) Employment 5) Military 6) Physical Health 7) Drug and Alcohol 8) Abstinence and Recovery Periods 9) Perceptions of Use 10) Behavioral and Emotional 11) Family/Social/Sexual

16. ASSESSMENT TOOL COMPONENTS continued 12) Recreational/Spiritual 13) Living Arrangements 14) Physical/Sexual/Emotional Abuse 15) Legal 16) Self-Care and Role Functioning 17) Consumer Factors 18) Assessment Worksheet/Results Information required for each of the above components, necessary to complete the LOC assessment and the LOCM Determination, can be found in the Case Management Manual on page twenty-three.

17. LEVEL OF CASE MANAGEMENT DETERMINATION • In addition to gathering the information necessary to determine the most appropriate level of care, the assessment is also used to identify other needs that the client may have, such as lack of transportation, housing, self-care, childcare, etc. • The assessment tool provided in the Case Management manual contains questions designed to correlate with the domains of the Inventory of Support Services (ISS) for adults. In this way, the assessment will aid the evaluator in determining whether or not a client would benefit from a referral for ICM services. The assessor’s clinical judgment, which includes the client’s own perception, is critical in determining the need for ICM services.

18. LEVEL OF CASE MANAGEMENT DETERMINATION continued • When the assessor identifies a need in six or more of the ISS domains, one of which is the drug and alcohol domain, the client must be offered a referral to ICM services.

19. LOCM DETERMINATION FORM BDAP has provided a LOCM Determination Form in the Case Management Manual. If the SCA or its sub-contractors choose not to use this form, documentation must include: • The 12 Domains and if there were identified needs in those domains; • Whether a referral to ICM was offered; • Whether the client accepted the referral; and • If a referral was not made, how the needs were appropriately addressed.

20. LEVEL OF CASE MANAGEMENT DETERMINATION continued • Resource Coordination (RC), which is not a mandated function of case management, may be offered to those clients who require a less intensive type of service. In this case, the assessor or treatment provider should supply information to the client or make referrals as deemed appropriate. • If a client is actively involved in treatment, the need for RC, if applicable, or ICM services, must continually be evaluated throughout the treatment experience. The SCA must have written protocols in place delineating how this evaluation occurs.

21. LEVEL OF CARE CONTINUED STAY PROCESS Detoxification Pre-approved detoxification treatment may occur for up to three (3) days. Treatment beyond the third day requires the completion of a continued stay PCPC Summary Sheet/ASAM that must be forwarded for approval. The summary sheets must also be maintained in the client file. Outpatient Pre-approved outpatient treatment may occur for up to six (6) months. Treatment beyond the six month period requires the treatment provider to document that the case was clinically staffed and that a continued stay PCPC Summary Sheet/ASAM was completed and maintained in the client file. CONTINUED STAY REVIEW

22. Partial Hospitalization/ Intensive Outpatient Pre-approved partial hospitalization or intensive outpatient treatment may occur for up to ten (10) weeks. Treatment beyond the ten week period requires the treatment provider to document that the case was clinically staffed and that a continued stay PCPC Summary Sheet/ASAM was completed and maintained in the client file. Inpatient Residential; Short-term Continued stay reviews are recommended every 14 days. A PCPC Summary Sheet/ASAM shall be completed and forwarded for approval. The summary sheets shall also be maintained in the client file. Inpatient Residential; Long-term to include Halfway House Continued stay reviews are recommended every 30 days. A PCPC Summary Sheet/ASAM shall be completed and forwarded for approval. The summary sheets shall also be maintained in the client file. CONTINUED STAY REVIEW continued

23. CLIENT LIABILITY AND ABATEMENT There shall be no client fee for initial services (assessment). Initial service refers to the services necessary to determine whether or not the individual is in need of diagnostic and treatment services, and to arrange for such services.

24. ICM OVERVIEW Referrals to ICM will be based on the needs of the client, either identified during the LOC assessment or during the course of treatment.

25. ICM • If a client is referred to ICM at the time of assessment or following admission to residential treatment, a contact with the client must occur within seven days prior to the projected date of discharge. A face-to-face meeting must occur within five days following the client's discharge from the facility. If there are deviations from either timeframe, documentation must be provided. • If a referral to ICM services is made at the time of assessment or following admission to non-residential treatment, a face-to-face appointment must be scheduled within seven days of the date of the referral. Extenuating circumstances may require this contact to occur via telephone to address any immediate needs the client may have.

26. ICM continued • If a referral to ICM services is made for a client not receiving drug and alcohol treatment services, a face-to-face appointment must be scheduled within seven days of the date of the referral. Extenuating circumstances may require this contact to occur via telephone to address any immediate needs the client may have.

27. ICM ADMISSION The SCA is required to have a written policy that describes the protocols for admission. The policy must state that the following items are to be completed with the client as part of the admission process: 1) An Agreement to Participate form; 2) Description of ICM services; 3) Discharge criteria; 4) Grievance and appeal procedure; 5) Follow-up requirements; 6) Appropriate consent forms; 7) Administration of ISS; and 8) Development of Service Plan.

28. ICM ADMISSION continued • The client must sign-off to verify that the above items have been reviewed in the admission process. • A client is admitted to ICM services once a service plan has been signed and completed. • All service plans must be completed within fourteen days of administration of the ISS.

29. ICM CLIENT TO STAFF RATIO • The client-to-staff ratio for ICM services must not exceed twenty-five to one (25:1) for case managers providing ICM services on a full-time basis. • The actual ratio may be lower and may be determined by the SCA. • If a case manager is part-time or is performing additional activities, such as those involvedin screening or assessment, client-to-staff ratios should be adjusted accordingly.

30. ICM WAITING LIST • The SCA must have a written policy that addresses the issue of waiting lists for clients referred to ICM services. • The policy must include what services will be provided, staff who will be monitoring the waiting list and how often it will be reviewed. • Clients with six or more identified domains,one of which is the AODT domain, must be given priority on the waiting list.

31. FREQUENCY AND TYPE OF CLIENT CONTACT The case manager must meet with the client as per the requirements listed below; however, more frequent contact may be necessary to address needs and to coordinate services. • First and second months following admission to ICM: A minimum of four contacts per month, at least two of which must be face-to-face. • From the third month following admission to ICM through discharge: A minimum of two contacts per month, at least one of which must be face-to-face. • Prior to discharge from ICM: It is recommended that a face-to-face contact occur prior to discharge from ICM. For clients in residential care, at least one contact must be made every 15 days.

32. ICM REASONS FOR DISCHARGE Completed ICM: Client has completed ICM e.g. support service needs have been adequately addressed and client is no longer in need of additional ICM services. Institutionalized / Incarcerated: Client is currently committed to a long-term psychiatric facility or has been incarcerated, either sentenced or pending disposition of his/her criminal case, for more than thirty days. Voluntary Discharge: Client indicated that he/she no longer wants the ICM services or support services that were being offered.

33. ICM REASONS FOR DISCHARGEcontinued Administrative Discharge: The SCA is required to specifically define administrative discharge. For example, the SCA would define how many missedappointments and in what time interval would initiate an administrative discharge. Transfer: Client has moved to another county within Pennsylvania and wishes to continue receiving ICM services. Other: Any other reasons for discharge that do not fit the above categories.

34. DISCHARGE FORM A discharge form is to be completed for each client at the point of discharge from ICM. The primary areas included in the discharge form are: 1) Client’s name; 2) Date of admission to ICM, date of discharge, and date of last contact: In some cases the date of last contact may be the discharge meeting. However, in cases where this discharge does not occur as part of a face- to-face meeting, the date of last contact should be the last time the case manager has had any direct contact with the client, either face-to-face or via telephone; 3) Reason(s) for discharge;

35. DISCHARGE FORM continued 4) Level of self-sufficiency: The case manager must record the level of self-sufficiency based on the ISS administered at the point of discharge. If the ISS is not administered at the point of discharge, a client’s progress or level of self-sufficiency should be determined by the scores of the last ISS; and, 5) The discharge form must be completed and signed by the case manager. The case management supervisor is only required to sign off on discharge forms if the client has not completed ICM.

36. ICM TRANSFER • The SCA is required to have a policy that describes the process of discharge/transfer of clients. • The SCA must accept an ICM priority client as identified by BDAP.

37. ICM TRANSFER continued • Documentation to be sent to the receiving SCA must include: • Completed ICM Discharge Form • Valid consent form • If there is a waiting list, the client must be placed on the waiting list.

38. CLIENT SATISFACTION SURVEY • Ideally, the CSS should be distributed to the client during a face-to-face contact with the case manager at the point of discharge. • The SCA is required to explain the CSS and process of administration of the survey. • The SCA is also required to provide documentation that indicates that the survey was distributed to the client within seven days of the date of discharge. • The SCA is required to have a written policy regarding the use and administration of the CSS.

39. ICM FOLLOW-UP • The Follow-Up Checklist must be administered at the following intervals: 30, 90, 180 days post discharge by the ICM staff person who managed the case, or another case manager, if the original staff member is not available. • Support/clerical staff must notadminister the Checklist. • Follow-up is required for all clients who have been discharged based on completion of ICM services.

40. ICM SERVICE PLAN • Service Plans must be completed within fourteen days of administration of the ISS. • Dated signature of case management supervisor is optional. • The Updated Service Plan has been eliminated.

41. CASE MANAGEMENT POLICY AND PROCEDURE MANUAL This manual must include, at a minimum, policies and procedures that address the following: 1) Client orientation 2) **Screening 3) Structure of the client files 4) Client grievance and appeal process 5) Supervision 6) **LOC Assessment 7) Liability and Abatement 8) Continued Stay Review 9) **Evaluation of the need for support services **Indicates a new requirement for the manual

42. CASE MANAGEMENT POLICY AND PROCEDURE MANUAL continued 10) ICM Referrals 11) Admission and readmissions to, and discharge/**transfer from ICM services. 12) **ICM waiting list 13) Follow-up 14) Client Satisfaction Survey 15) **Confidentiality 16) **Provider reporting, as applicable **Indicates a new requirement for the manual

43. POLICY AND PROCEDURE MANUAL continued The manual must also include the following items: 1) **SCA’s definition of case management philosophy 2) Structure of case management system; **including client access 3) **Description of RC, if provided 4) Current community resource list **Indicates new requirements for the manual

44. CASE MANAGEMENT FILE CONTENT The files for case management clients may be combined into one chart. Case Management client files must, when applicable, include required items as follows:

45. FILE CONTENT continued

46. SUPERVISION REQUIREMENTS • In order to ensure the adequate provision of case management services, supervisory staff must have a working knowledge of all information and responsibilities required of case management staff; therefore, case management supervisors must, at a minimum, complete all required case management core trainings. • In order to ensure timely and effective delivery of services, completion of appropriate documentation, the SCA and/or its’ sub-contracted case management providers must have a written supervision policy which details the following information:

47. SUPERVISION REQUIREMENTScontinued 1) Manner and frequency of supervision for both case management specialists as well as case management specialist trainees. In the case of a sub-contracted treatment provider, this would include any counselor or counselor assistant providing case management services on behalf of the SCA; 2) The manner and frequency for completing chart reviews for both active and discharged clients; 3) The manner in which supervision and chart reviews will be documented; 4) The process for allowing new staff to perform case management functions without having received required/related core trainings, which must include a combination of job shadowing and direct observation. Close supervision and supervisory sign-off on written documentation until the case manager has received all appropriate training.

48. STAFFING QUALIFICATIONS • Case managers employed by a sub-contracted drug and alcohol treatment provider must meet the DOH licensing requirements for either Counselor or Counselor Assistant. Those persons responsible for supervision of case managers must meet, at a minimum, the DOH licensing requirements for Clinical Supervisor or Lead Counselor. In addition, case managers and supervisors must complete required core trainings as defined in the training section of the Case Management Manual.

49. CASE MANAGEMENT CORE TRAININGS • The SCA is required to ensure that those persons providing case management functions, either at the SCA or sub-contracted providers, complete all required and applicable case management core trainings within 365 days of hire. • The practicum courses listed in the following slides are required for persons in the field who have not taken the 6 - hour Confidentiality training and/or 6 - hour PCPC training prior to November 1, 2003.

50. CASE MANAGEMENT CORE TRAININGScontinued Course selection and completion requirements depend upon which functions the case manager has been assigned to perform. The course requirements for each function are outlined below: Assessment Function - 42 total training hours • Addictions 101 – 6 hours • Confidentiality – 6 hours • Practical Application of Confidentiality Laws and Regulations – 3 hours • Case Management Overview – 6 hours • Screening & Assessment - 6 hours • PCPC – 6 hours • Practical Application of PCPC Criteria – 3 hours • Adolescent ASAM – 6 hours