Case Management: Records, ROI, and Service Plans

Records: Receiving and Sending

• Receiving: Case managers gather records to:

  • Understand client history.

  • Inform providers.

• Sending: Requires ROIs for referrals.

• Protocols: Agency-specific.

Release of Information (ROI)

• Purpose: Needed to share records; get client consent early.

• Process:

  • Explain ROI.

  • Obtain client consent.

• Guidelines:

  • Share only necessary data; avoid blanket ROIs.

  • Specify provider, information, and timeframe.

  • Follow agency guidelines.

• Legal & Ethical:

  • Unauthorized release is illegal.

  • Clients can cancel ROIs.

  • Protect client privacy; do not pressure clients.

• Details: Be mindful of ROI specifics.

Specific Considerations for ROI

• Sensitive Data (HIV, mental health, substance use):

  • Needs extra protection.

  • Ensure proper release.

  • Redact if needed.

• Consultation: Consult the agency in unique situations; never share records without consulting.

• Communication: ROIs needed for client communication, except for HIPAA TPO.

Crafting a Service Plan

• Definition: Driven by assessments, specifies goals and interventions.

• Components:

  • Identify needs.

  • Set goals.

  • Determine interventions.

• Types: Treatment plans and general care plans may include coaching.

The Service Plan Process

• Assessments: Link needs to goals/interventions/providers.

• Prioritization: Prioritize needs with the client to set broad goals.

• Outcomes: Providers create measurable outcomes linked to interventions.

• Details: Plans detail the problem, goal, intervention, and responsible party.

Documenting the Service Plan

• Information: Include client info, plan details, and those involved.

• Elements:

  • Document needs, goals, intervention plan, and referrals.

  • Add strengths and resources.

  • List barriers.

  • Include a safety plan, if necessary.

Anticipating Barriers

• Context: Clients face barriers, necessitating case management.

• Action: Identify and address barriers like:

  • Communication issues.

  • Cultural factors.

  • Disabilities.

  • Limited resources.

  • Health issues.

Case Staffing

• Purpose: Staff collaborate to review/finalize service plans.

• Involvement: The client may or may not be involved.

• Goal: Seek and provide:

  • Feedback.

  • Ideas.

  • Resource advice.

• Process: Plan revision and finalization.

• Format: Varies; complex cases may require interdisciplinary meetings.

Presenting the Case

• Presenter: The case manager gives a brief summary:

  • Client demographics/diagnosis.

  • Systems snapshot/eco map.

  • Chief complaints and needs.

  • Client perspective and assessment.

  • Tentative plan - be open to feedback.

Following Up after the Meeting

• Documentation: Document the meeting; integrate feedback into the final plan.

• Approval: Get approval and client/provider feedback.

• Referrals: Make referrals with signed ROIs.

• Communication: Follow up with experts and clients; clearly communicate appointments, contact methods, and expectations.