Current through Register Vol. 46, No. 19, March 20, 2024
Case management service activities include the following
components.
(1)
Client
identification. The provider of the service of case management may
identify clients through public education, awareness, and outreach.
(2)
Intake. The provider of
the service of case management shall follow a defined intake process developed
or approved by the department. To become eligible for the service of case
management, a potential client with case management needs shall:
a. Be a legal resident of the state of
Iowa;
b. Be aged 60 or
older;
c. Be in need of the service
of case management based on a needs assessment as described in subrule
21.4(3);
d. Be funded through Title
III (Grants to State and Community Programs on Aging) of the OAA or state funds
distributed to the AAA based upon their current area plan; and
e. Not be entitled to receive case management
services or case management service reimbursement from another
source.
(3)
Needs assessment. A face-to-face comprehensive assessment,
utilizing a standardized tool developed or approved by the department and
preferably conducted in the client's home or place of residence, must be
conducted for each case management client to identify the conditions and needs
of the client and to establish goals for services provided.
(4)
Service plan
development. Based on a standardized form developed or approved by the
department, a written service plan shall be prepared for each client. The
service plan shall utilize appropriate and available resources.
a. The service plan shall be developed within
20 calendar days of the needs assessment.
b. The service plan shall identify available
services and problem-solving efforts to meet the client's determined needs and
to enable the client to live with maximum possible independence.
c. A copy of the service plan shall be given
to the client or the client's legal representative and shall be documented in
the client's file.
(5)
Service plan implementation. A referral of the client to an
appropriate resource for service provision and problem resolution shall be made
and documented in the client's file. If the referral is made to an informal
network (e.g., family, friends), the service and problem-solving arrangement
agreed to regarding duties and responsibilities shall be documented in the
client's service plan. The following services shall be performed for each
client, as appropriate and needed:
a. Active
intervention and advocacy on behalf of the client to access necessary services
from community organizations and to resolve problems experienced by the
client;
b. Establishment of
connections with service providers for the prompt and effective delivery of
services needed by the client, including submission of instructions for service
delivery to the appropriate service providers;
c. Encouragement of informal care given by
individuals, family, friends, neighbors, and community organizations, so that
publicly supported services supplement rather than supplant the roles and
responsibilities of these natural support systems.
(6)
Follow-up and reassessment of
client status.
a.
Follow-up. Monthly monitoring of each client shall be
conducted through telephone or face-to-face contact to ensure prompt and
effective service delivery and response to changes in the client's needs and
status. All follow-up shall be documented in the client's file.
b.
Reassessment. A
face-to-face needs assessment of the client's condition and needs must be
conducted in accordance with subrule 21.4(3), preferably in the home of the
client, no later than the twelfth month from the last completed needs
assessment. This needs assessment must be conducted more frequently if a change
in the client's circumstances is identified in a follow-up or a report from a
third party.
(7)
Client discharge.
a. A
client shall be discharged from the service of case management when any one of
the following situations has occurred:
(1) The
client dies;
(2) The client moves
out of state;
(3) The client moves
into a nursing facility and the stay is expected to be permanent;
(4) The client or the client's legal
representative requests termination of case management service;
(5) The client is unwilling or unable to
adhere to the agreed-upon service plan;
(6) The client or the client's legal
representative refuses to provide access to information necessary for the
development or implementation of the service plan;
(7) The service provider determines that the
client's needs cannot be met in a way that ensures the client's health, safety
and welfare;
(8) The service
provider determines that the client's goals are achieved and the client no
longer requires the service of case management;
(9) The client becomes eligible for a
comparable case management service from another funding source; or
(10) The AAA determines that funding is no
longer available to provide the service of case management.
b. A point of contact identified
by the AAA shall be notified of and approve all discharges prior to initiation
of discharge action.
c. If the
discharge is due to the circumstances given in subparagraphs
21.4(7)"a"(5) to 21.4(7)"a"(9), the AAA
providing the service of case management shall provide a 30-day written notice
to the client or the client's legal representative stating the reasons for the
discharge from case management and include the process for appealing the
decision in accordance with rule
17-6.10
(231).
(8)
Transfer. When a client moves from the AAA's geographic
service area, the AAA shall, with the documented consent of the client or the
client's legal representative, refer the client to the AAA serving the area to
which the client has moved.
(9)
Monitoring and follow-up. The AAA shall, and the department
may, monitor and follow up with providers of the service of case management.
a. Monitoring shall be conducted to determine
whether:
(1) Services are being furnished in
accordance with the client's service plan, including the amount of service
provided, the client's attendance, and the client's participation in the
service.
(2) The client has
declined services in the service plan.
(3) Communication is occurring among all
providers to ensure coordination of services.
(4) Services in the service plan are meeting
the identified needs of the client, including the client's progress toward
achieving the goals and actions determined in the service plan.
b. Monitoring shall include
accessing and assessing the client, the places of service (including the
client's home when applicable), and all services.
(10)
Records and
documentation.
a. A case management
service provider shall maintain individual client records in a paper file or in
a case management software database approved by the department. The case file
for each client shall minimally include the following information:
(1) Intake form(s);
(2) Comprehensive needs assessment;
(3) Copies of release of information (if
needed);
(4) Service
plan;
(5) Record of referral(s) and
request(s);
(6) Correspondence
related to the case;
(7) Formal
case notes, which include documentation of the follow-up as noted in paragraph
21.4(6) "a" or of case closure.
b. Except by written consent of the client or
the client's legal representative, the use or disclosure by any person of any
information concerning a client for any purpose not directly connected with the
administration of the responsibilities of the department, AAA or contractor is
prohibited.
c. Upon change in AAA
designation, the AAA which has been dedesignated shall transfer all specified
records as prescribed by the department to the newly designated AAA.
These rules are intended to implement Iowa Code section
231.23
A.
