2024 Edition

Case Management Definition

Purpose

Individuals and families who receive Case Management services access and use resources and supports that build on their strengths and meet their service needs.

Definition

Case Management services plan, secure, coordinate, monitor, and advocate for unified goals and services with organizations and personnel on behalf of individuals and families.

Intensive Case Management services are provided by a case manager who has an established relationship with the person served and delivers and/or coordinates a comprehensive array of services through ongoing support and frequent contact.
 
 

Note:COA's Case Management standards apply to stand-alone case management programs. Organizations that provide Foster Care Case Management Services are accredited under COA's Family Foster Care and Kinship Care (FKC) standards and not Case Management.


Note: Please see CM Reference List for a list of resources that informed the development of these standards.  


Note:For information about changes made in the 2020 Edition, please see the CM Crosswalk.  

2024 Edition

Case Management (CM) 1: Person-Centered Logic Model

The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.

Note: Please see the Logic Model Template for additional guidance on this standard.  

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.

Logic models have been implemented for all programs and the organization has identified at least two outcomes for all its programs.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Logic models need improvement or clarification; or
  • Logic models are still under development for some of its programs, but are completed for all high-risk programs such as protective services, foster care, residential treatment, etc.; or
  • At least one client outcome has been identified for all of its programs; or
  • All but a few staff have been trained on use of therapeutic interventions and training is scheduled for the rest; or
  • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Logic models need significant improvement; or
  • Logic models are still under development for a majority of programs; or
  • A logic model has not been developed for one or more high-risk programs; or
  • Outcomes have not been identified for one or more programs; or
  • Several staff have not been trained on the use of therapeutic interventions; or
  • There are gaps in monitoring of therapeutic interventions, as required; or
  • There is no process for identifying risks associated with use of therapeutic interventions; or
  • Policy on prohibited interventions does not include at least one of the required elements.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • Logic models have not been developed or implemented; or
  • Outcomes have not been identified for any programs; or
  • There is no written policy or procedures for the use of therapeutic interventions; or 
  • Procedures are clearly inadequate or not being used; or
  • Documentation on therapeutic interventions is routinely incomplete and/or missing; or
  • There is evidence that clients have been harmed by inappropriate or unmonitored use of therapeutic interventions.
 

CM 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, organizational, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered); 
  5. desired outcomes (i.e. the changes you expect to see in service recipients); and
  6. expected long-term impact on the organization, community, and/or system.

Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA's PQI Tool Kit for more information on developing and using program logic models.

Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to:  
  1. needs assessments and periodic reassessments; and
  2. the best available evidence of service effectiveness.   
 

CM 1.02

The logic model identifies client outcomes in at least two of the following areas:
  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation; 
  5. quality of life; 
  6. achievement of individual service goals; and 
  7. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 

2024 Edition

Case Management (CM) 2: Personnel

Case management personnel have the competency and support needed to access, coordinate, and provide services and meet the needs of individuals and families.
Interpretation: Competency can be demonstrated through education, training, or experience. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised; or
  • Supervisors provide additional support and oversight, as needed, to the few staff without the listed qualifications; or 
  • Most staff who do not meet educational requirements are seeking to obtain them; or 
  • With few exceptions, staff have received required training, including applicable specialized training; or
  • Training curricula are not fully developed or lack depth; or
  • Training documentation is consistently maintained and kept up-to-date with some exceptions; or
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies when needed; or
  • With few exceptions, caseload sizes are consistently maintained as required by the standards or as required by internal policy when caseload has not been set by a standard; or
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services and are adjusted as necessary; or
  • Specialized services are obtained as required by the standards.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards.  Service quality or program functioning may be compromised; e.g.,
  • A significant number of staff (direct service providers, supervisors, and program managers) do not possess the required qualifications, including education, experience, training, skills, temperament, etc.; and as a result, the integrity of the service may be compromised; or
  • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur; or 
  • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications; or
  • A significant number of staff have not received required training, including applicable specialized training; or
  • Training documentation is poorly maintained; or
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies; or
  • There are numerous instances where caseload sizes exceed the standards' requirements or the requirements of internal policy when a caseload size is not set by the standard; or
  • Workloads are excessive, and the integrity of the service may be compromised; or 
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
 

CM 2.01

Case managers are qualified by:
  1. a bachelor’s degree in a human service field;
  2. case management certification; or
  3. a bachelor’s degree in a field other than a human service, with appropriate experience.
 

CM 2.02

Supervisors of case managers are qualified by:
  1. an advanced degree in social work or a comparable human service field and a minimum of two years’ experience in direct services or case management;
  2. a bachelor’s degree in a human service field and four years' experience in direct services or case management; and/or
  3. licensure or certification in case management and four years' experience in direct services or case management.
 

CM 2.03

Case managers receive training on, or demonstrate competency in, the following topics:
  1. coordinating services as part of a team;
  2. linking service recipients, and making referrals to, community services; and
  3. knowledge of public assistance programs, eligibility requirements, and benefits.
 

CM 2.04

The organization maintains service continuity for individuals and families by:
  1. assigning a worker early in the contact, when appropriate; and
  2. minimizing the number of workers assigned to persons served over the course of their contact with the organization.
 

CM 2.05

Caseload sizes are sufficiently small to permit case managers to respond flexibly to differing service needs of individuals and families, including frequency of contact, and to support the achievement of client outcomes.

Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; and
  3. service volume, accounting for assessed level of needs of persons served.
2024 Edition

Case Management (CM) 3: Intake and Assessment

The organization's intake and assessment practices ensure that individuals and families receive prompt and responsive access to appropriate services.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
 

CM 3.01

Individuals and families are screened and informed about:
  1. how well the request matches the organization's services; and 
  2. what services will be available and when.
NA Another organization is responsible for screening, as defined in a contract.
 
Fundamental Practice

CM 3.02

Prompt, responsive intake practices:
  1. include screening for level or intensity of service;
  2. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  3. give priority to urgent needs and emergency situations;
  4. support timely initiation of services; and
  5. provide for placement on a waiting list or referral to appropriate resources when individuals and families cannot be served or cannot be served promptly.
 

CM 3.03

Individuals and families participate in an individualized, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. updated as needed based on the needs of persons served; and
  3. focused on information pertinent for meeting service requests and objectives.

Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

 

CM 3.04

The organization conducts the assessment in-person, in a place of the individual’s or family's choice, when possible, and: 
  1. includes assessment of natural supports and helping networks; and 
  2. promptly provides or makes arrangements for specialized assessments, as needed.
 

CM 3.05

Individuals and families participate in a formal re-assessment annually or more frequently based on the following criteria:
  1. within five working days of a precipitating event;
  2. when there is a change in their status or circumstances, or a new issue arises; and
  3. within 48 hours of notification that hospital or institutional discharge is imminent.
Interpretation: An organization that, due to contractual requirements, is unable to conduct event-based re-assessments according to these timeframes should modify them to meet the needs and goals of persons served.
2024 Edition

Case Management (CM) 4: Service Planning and Monitoring

Each individual or family participates in the development and ongoing review of a service plan that is the basis for coordination and delivery of appropriate services and support.

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VIEW THE STANDARDS

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.  
 

CM 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s signature.
 
Fundamental Practice

CM 4.02

The organization works in active partnership with individuals and families to:
  1. directly provide, or arrange for necessary services;
  2. provide case coordination and monitoring of services; 
  3. ensure that they receive appropriate advocacy support; 
  4. assist with access to the full array of services to which they are eligible; and
  5. mediate barriers to services within the service delivery system.

Examples: Personnel can help to engage and motivate individuals and families in this process by demonstrating: 
  1. sensitivity to their needs and personal goals;
  2. a non-threatening manner;
  3. respect for their autonomy, confidentiality, sociocultural values, lifestyle choices, and complex family interactions;
  4. flexibility; and
  5. appropriate boundaries.
 

CM 4.03

The organization maintains a comprehensive, up-to-date list of community programs and services, and information on how to access them.
 

CM 4.04

Service monitoring includes:
  1. confirmation, usually within one or two working days, that a service has been initiated as scheduled;
  2. verification, usually within 15 working days, that the service is appropriate and satisfactory;
  3. follow-up every three months; and
  4. immediate response to any complaints or problems that develop in the delivery of services or with the individual or family receiving services.
Interpretation: The organization should tailor the type and frequency of service monitoring according to the needs of individuals and families, frequency and intensity of service provided, and frequency of contact with informal caregivers and cooperating providers.
 

CM 4.05

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly or more frequently depending on the needs of individuals and families, to assess:
  1. service plan implementation;
  2. the individual’s or family’s progress toward achieving goals and desired outcomes; and
  3. the continuing appropriateness of agreed upon service goals.
Interpretation: When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.
 

CM 4.06

Workers and persons served, and their family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.
2024 Edition

Case Management (CM) 5: Intensive Case Management

Intensive case management services connect individuals and families to a coordinated, comprehensive array of services that meet their ongoing needs.
NA The organization does not provide Intensive Case Management Services.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
 
Fundamental Practice

CM 5.01

As needed, the organization directly provides, or formally arranges for, and coordinates:
  1. 24-hour crisis intervention;
  2. psychiatric services;
  3. housing services;
  4. medical and dental services;
  5. alcohol and other drug education and treatment;
  6. public assistance and income maintenance;
  7. family support services;
  8. vocational training and job placements; and
  9. transportation.
 

CM 5.02

Case managers help individuals and families strengthen and manage the quality of their lives by:
  1. initiating change agent activities;
  2. teaching problem solving skills; and
  3. modeling productive behaviors.
 
Fundamental Practice

CM 5.03

Caseload sizes range between 10 and 15 cases depending on the needs of individuals and families, the goals sought by the intervention, and the frequency of contact.
 

CM 5.04

The organization makes direct contact with the individual or family at least four times per month.
 
Fundamental Practice

CM 5.05

A psychiatrist or another qualified health practitioner with experience appropriate to the level and intensity of service and persons served, is responsible for the psychiatric aspects of the program.
Interpretation: The organization may use a consulting psychiatrist or community mental health center with which it has a formal agreement for psychiatric consultation.
2024 Edition

Case Management (CM) 6: Case Closing and Aftercare

The organization works with individuals and families to plan for case closing and, when possible, to develop aftercare plans.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,   
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, the organization terminated services inappropriately; or  
  • Active client participation occurs to a considerable extent; or
  • A formal case closing evaluation is not consistently provided to the public authority per the requirements of the standard.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Services are frequently terminated inappropriately; or  
  • Aftercare planning is not initiated early enough to ensure orderly transitions; or
  • A formal case closing summary and assessment is seldom provided to the public authority per the requirements of the standard; or  
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing. 
 

CM 6.01

Planning for case closing:
  1. is a clearly defined process that includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, persons served, and others as appropriate to the needs and wishes of the consumer.
 

CM 6.02

Upon case closing, the organization notifies any collaborating service providers, as appropriate.
 

CM 6.03

If an individual or family has to leave the program unexpectedly, the organization makes every effort to identify other service options and link them with appropriate services.
Interpretation: The organization must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits are denied or have ended and who are in critical situations.
 

CM 6.04

When appropriate, the organization works with persons served and their family to:
  1. develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and facilitates the initiation or continuation of needed supports and services; or
  2. conduct a formal case closing evaluation, including an assessment of unmet need, when the organization has a contract with a public authority that does not include aftercare planning or follow-up.
 

CM 6.05

The organization follows up on the aftercare plan, as appropriate, when possible, and with the permission of the individual or family.
NA The organizations has a contract with a public authority that prohibits or does not include aftercare planning or follow-up.

Examples: Reasons why follow-up may not be appropriate include, but are not limited to, cases where participation is involuntary, or where there can be a risk to persons served such as in cases of domestic violence.
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