BEHAVE 400 Case Management - Module 8 Video Lecture Notes

Records: Receiving and Sending

1. Introduction

   • Transition from general helping skills to specific case management.

   • Foundational skills ensure effective job performance.

   • Rapport and trust are vital for gathering accurate information.

   • Focus on records management and service plan development.

2. Requesting/Receiving and Releasing/Sending Records
   a. Importance
   - Essential for case managers as service coordinators.
   - Assess client needs and connect them with resources.
   b. Benefits
   - Ensures continuous care and better communication.
   - Prevents service duplication and identifies ineffective treatments.
   - Helpful for clients with memory or cognitive issues.
   - Offers objective documentation and fills in missing details.
   - Facilitates a holistic understanding of the client.

3. Sending Records and Referrals

   • Link clients with providers to meet needs and goals.

   • Send referrals to other professionals.

   • Follow agency-specific referral protocols.

   • Core component of case management.

4. Release of Information (ROI)
   a. Process
   - Client permission is required via ROI.
   - Obtain ROIs during the first session, if possible.
   - Explain the ROI process clearly for informed consent.
   b. Client Rights
   - Clients have the right to fully understand the ROI.
   - Explain the difference between needing vs. requiring ROI.
   c. Best Practices
   - Read and explain the form carefully.
   - Only request and send necessary information.
   - Avoid blanket ROIs; keep information specific and time-limited.
   - Advise against open-ended ROIs for client safety.
   - Use time frames (90 days to 6 months) per agency guidelines.
   d. Agency Procedures
   - Some agencies have central ROI handling departments.
   - Releasing data without or beyond the scope of an ROI is unethical and illegal.
   - Clients can cancel an ROI after signing.
   e. Privacy and Ethics
   - Protect client privacy and data as a top priority.
   - The ROI need shouldn't overshadow client self-determination.
   - Explain benefits and consequences of releasing information.
   - Only release pertinent information; adhere to marked boxes on the ROI.
   f. Special Cases
   - Clients can limit requests to specific record types.
   - Set ROIs to expire to minimize risk.
   - For deceased clients, follow state laws and consult the agency.
   - Consult the agency for other parties requesting records.
   - Never hand over, fax, or email records without consultation.

5. Most Common Information Sent

   • Assessments by the case manager or agency.

   • Client correspondence.

   • ROI needed for communications (except HIPAA TPO).

   • TPO exception covers insurance for payment and services.

   • Insurance and hospitals often have case managers.

6. General ROI Components

   • Client name, date of birth, and purpose.

   • Expiration date and relevant information with date ranges.

   • Client/guardian and staff signatures.

   • Review information with the client.

7. Special Considerations for Stigma-Related Information
   a. Types of Protected Information
   - HIV, behavioral health, and substance use data require extra caution.
   - Follow agency protocols strictly.
   b. HIV Information
   - Highly protected; may need explicit consent and redaction.
   c. Behavioral Health Records
   - Highly protected; adhere to stringent confidentiality rules.
   d. Substance Use-Related Records
   - Highly protected under federal regulations.
   e. Other Sensitive Records
   - Domestic violence and criminal records also require caution.
   - Double-check releases and protocols.

8. Example ROI Scenarios

   • Agency requests and information types needed.

   • DSHS of Washington release includes special records section (HIV, mental health, substance use).

   • Clients can revoke permission in writing.

   • Prioritize protecting client data; follow agency protocols and consult supervisors.

9. Service Plan Development
   a. Core Function
   - Key part of case management.
   - Understand needs, goals, and interventions.
   b. Service Plan Details
   - Similar to a treatment plan, driven by assessment needs.
   - Assessments guide the service plan.
   c. Service Plan Goals
   - Covers health, mental health, substance use, and well-being.
   - Achieved through provider or client interventions.
   d. Types of Plans
   - Treatment Plans: Specific to behavioral/physical health.
   - General Care Plans: Holistic plans for institutionalized settings.
   - Coaching Plans: Focus on client actions (diet, exercise).
   e. Client Empowerment
   - Implement plans to boost client self-efficacy.
   - Address a wide array of client needs.

10. Assessment to Service Plan Linkage

    • Assessments guide plans, needs become goals.

    • Use biopsychosocial-spiritual assessments.

    • Prioritize goals with the client.

    • Initial goals can be broad.

    • Providers tailor goals into measurable outcomes.

    • Case Management = problem -> need -> goal -> intervention -> assigned person.

    • Example: Housing need -> affordable housing in 60 days.

    • Address physiological needs first (Maslow's hierarchy).

11. Documenting the Service Plan

    • Record client data, contacts, dates, and review details.

    • Note who assisted in creating the plan.

    • Document needs, problems, goals, plans, and referrals.

    • Include major players (doctors, therapists).

    • Confirm client access to provider information.

    • Refer to agencies with multiple service offerings.

    • Document strengths, resources, and protective factors.

    • Maximize use of existing supports.

    • Document potential barriers or risks, and mitigate them.

    • Develop a safety plan, if needed.

    • Customize service plans to each case.

12. Anticipating Barriers

    • All clients encounter barriers.

    • Explore unmet needs and underlying obstacles.

    • Adapt planning based on client challenges.

    • Assess and address language barriers (interpreters).

    • Understand the client’s perspective.

    • Consider time factors (work, responsibilities).

    • Recognize symptoms interfering with treatment.

    • Strategize creatively with the client.

    • Secure additional resources.

13. Staffing Service Plans

    • Staffing Conference = meeting with multiple experts.

    • Incorporate specialized knowledge and skills.

    • Client involvement varies.

    • The goal is to be better and provide input.

    • The format depends on the case.

    • The case manager leads the meeting.

    • Focus on collaborative and goal-oriented discussions.

14. Staffing Issues

    • Encourage collaboration and a growth mindset.

    • Prepare relevant questions and resources.

    • Maintain an updated list of diagnoses.

    • Thoroughly prepare for each case.

    • Bridge information gaps through individual meetings.

    • Finalize goals during meetings.

15. Things to Prepare For and Do

    • Provide a concise overview of problems and issues.

    • Share relevant diagnoses and observations.

    • Be receptive to feedback.

    • Avoid defensiveness.

    • Document meeting details.

    • Engage a scribe.

16. After Meetings: Follow Up

    • Document meeting details using agency protocols.

    • Avoid making isolated decisions.

    • Integrate recommendations and seek supervisor approval.

    • Follow up with contributors and supervisors.

    • Facilitate agency-approved referrals.

    • Arrange post-referral follow-up meetings.

    • Establish collateral contacts.

    • Maintain ongoing communication with the client.

17. Example Presentation

    • Present