Common use of Implementation of the Individualized Case Plan Clause in Contracts

Implementation of the Individualized Case Plan. 1. Implementation of the individualized Case Plan involves ongoing contact and interventions with, or on behalf of, the client to ensure goals and objectives are addressed. 2. In the implementation and reassessment phase, Case Managers shall be responsible for, at a minimum, the following: a. Providing linkage referrals, client advocacy, and appropriate interventions based on the intake, assessment, and Case Plan; b. Empowering client to develop and use their independent living skills and strategies; c. Conducting ongoing monitoring and follow-up with client and Providers to confirm completion of referrals, services are obtained and maintained, and adherence to services; d. Monitoring changes in the client’s condition or circumstances, providing interventions and linked referrals as outlined in the Case Plan utilizing Recipient approved referral forms (“Referral Forms”), and updating the Case Plan to reflect changes in the client’s circumstances or needs that have been addressed; e. Assessing adherence to medications and medical appointments, and monitoring laboratory values to assess adherence to medications and changes in the client’s immune system; f. Ensuring care is coordinated among the client, family members, other caregivers, Medical Care Providers, and other Service Providers; g. Actively following-up after discharge from the hospital (when the Case Manager is aware of the hospitalization); h. Undertaking activities to ensure Xxxx Xxxxx Program funds are the payer of last resort, clinical and other services are synchronized, health insurance benefits are coordinated among payers, follow-up activities are conducted, and the client does not experience gaps in benefits or health services; i. Advocating on behalf of client with other Service Providers; j. Resolving barriers to completing referrals, and accessing client adherence to healthcare and treatment regimens; k. Actively following up on established goals and objectives in the Case Plan to evaluate the client’s progress and determine appropriateness of services; l. Maintaining ongoing client contact as outlined in the Case Plan; and m. Actively following-up with client’s who have missed medical and dental appointments. 3. Case Managers shall document progress logs in Provide Enterprise to document their activities during the implementation of the Case Plan. Current, dated and signed progress logs detailing activities related to implementing and evaluating the Case Plan shall be kept on file in the client’s record. 4. The following documentation shall be required (at a minimum): date and time of the activity; client’s acuity level; type of activities conducted and if the activity was conducted face-to-face; non-face-to-face activities; goals in the Case Plan addressed by the activity; activities undertaken to address each goal; comments regarding the activities undertaken; and the number of units for each goal and the total units completed.