Adult TCM

Assessments: Conducts assessment of assigned clients to include Preliminary Bio-psychosocials, Psychosocials /Comprehensive Assessment, Medical Questionnaires, and all related intake assessments in a timely manner (within 30 days of intake). Contacts others (family and other providers, with appropriate consent) to provide information for the assessment as appropriate. Updates required assessments in accordance with Client Record Handbook guidelines. Finalize all documents in Avatar and turn in all assessment within 24 hours. Maintain 85% compliance with assessment requirements.

Home Visits: Conducts home visits prior to completion of the intake assessment process to evaluate the safety and well being of the client in the setting the client resides in unless staffed with supervisor and written justification is provided in the record as to why the home visit could not be made. Utilize laptop as appropriate. Meets at least 85% compliance with home visit requirements on Clinical Reviews conducted during rating period.

Client Service Plans: Develops individualized service plans in partnership with the client and the client’s guardian (if applicable). Develops service plans that include measurable goals and objectives derived from the client’s assessment, identified time frames for achievement on goals which are signed and dated by the client and client’s guardian, if applicable. Updates service plans at least every 6 months or at any time significant changes occur in the client’s condition, situation, or circumstances (e.g., hospitalizations, achievement of goals, etc). Maintain at least 85% compliance with Client Service Plan requirements.

Case Management: Assists clients in gaining access to needed financial and insurance benefits, employment, medical, social, education, and other services. Works with the client and the client’s natural support system to develop and implement the client’s service plan. Utilize and maintain the Level of Care system as monitoring tool to determine appropriate level of care is provided. Follows-up on the client’s services to determine the status of the client’s services and the effectiveness of the service plan towards enhancing the client’s inclusion in the community. Maintain at least 85% compliance with case management service requirements.

Service Provision: Meets Service Productivity standard of at least 75% (or 6 out of 8 work hours) for the provision of Case Management services in accordance with applicable clinical/quality criteria which are supported by appropriate clinical record documentation which meet Client Record Handbook specifications, Avatar documentation requirements, and Agency business/clinical ethical standards.

Progress Notes: Documents all services provided in the client record in accordance with Client Record Handbook Guidelines. Document must be finalized in Avatar within 24 hours from the time the service was rendered. Progress notes must be detailed and clearly reflect how the case manager’s efforts are linked to the services and goals in the client’s service plan and the client’s progress or lack of progress relative to the service plan. Maintain at least 85% compliance with progress note requirements on Clinical Reviews conducted during rating period.

High Risk Clients: Identifies high risk clients and completes suicide risk assessments for all clients during the intake and/or at any time during treatment a client is noted to have suicide ideation, plans, or an attempt. Reviews risk assessments with the Supervisor and/or MD/ARNP and routes the form to appropriate staff upon completion. Individual note must be documented to reflect the staffing with treatment team. Includes suicide risk, ideations, plans, or recent attempt as a problem statement with measurable objectives, (to include a monitoring schedule), and appropriate treatment intervention(s) on the CSP. Assists the client in completing the Personal Safety Plan. Maintains at least 85% compliance with suicide risk assessment requirements on Clinical Reviews conducted during rating period.