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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
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. Agencies that provide Foster Care Case Management Services are accredited under COA's Family Foster Care and Kinship Care (PA-FKC) standards and not Case Management.
Note: Please see PA-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.
Case Management (PA-CM) 1: Person-Centered Logic Model
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-CM 1.01
- needs the program will address;
- available human, financial, agency, and community resources (i.e. inputs);
- program activities intended to bring about desired results;
- program outputs (i.e. the size and scope of services delivered);
- desired outcomes (i.e. the changes you expect to see in service recipients); and
- expected long-term impact on the agency, community, and/or system.
Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to:
- needs assessments and periodic reassessments; and
- the best available evidence of service effectiveness.
PA-CM 1.02
- change in clinical status;
- change in functional status;
- health, welfare, and safety;
- permanency of life situation;
- quality of life;
- achievement of individual service goals; and
- 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 PA-PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes.
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Case Management (PA-CM) 2: Personnel
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-CM 2.01
- a bachelor’s degree in a human service field;
- case management certification; or
- a bachelor’s degree in a field other than a human service, with appropriate experience.
PA-CM 2.02
- 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;
- a bachelor’s degree in a human service field and four years' experience in direct services or case management; and/or
- certification, registration, or a license to practice in case management and four years' experience in direct services or case management.
PA-CM 2.03
- coordinating services as part of a team;
- linking service recipients, and making referrals to, community services; and
- knowledge of public assistance programs, eligibility requirements, and benefits.
PA-CM 2.04
- assigning a worker early in the contact, when appropriate; and
- minimizing the number of workers assigned to persons served over the course of their contact with the agency.
PA-CM 2.05
- the qualifications, competencies, and experience of the worker, including the level of supervision needed;
- the work and time required to accomplish assigned tasks and job responsibilities; and
- service volume, accounting for assessed level of needs of persons served.
Case Management (PA-CM) 3: Intake and Assessment
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-CM 3.01
- how well the request matches the agency's services; and
- what services will be available and when.
PA-CM 3.02
- include screening for level or intensity of service;
- gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
- give priority to urgent needs and emergency situations;
- support timely initiation of services; and
- provide for placement on a waiting list or referral to appropriate resources when individuals and families cannot be served or cannot be served promptly.
PA-CM 3.03
- completed within established timeframes;
- updated as needed based on the needs of persons served; and
- 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.
PA-CM 3.04
- includes assessment of natural supports and helping networks; and
- promptly provides or makes arrangements for specialized assessments, as needed.
PA-CM 3.05
- within five working days of a precipitating event;
- when there is a change in their status or circumstances, or a new issue arises; and
- within 48 hours of notification that hospital or institutional discharge is imminent.
Case Management (PA-CM) 4: Service Planning and Monitoring
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-CM 4.01
- agreed upon goals, desired outcomes, and timeframes for achieving them;
- services and supports to be provided, and by whom;
- possibilities for maintaining and strengthening family relationships and other informal social networks;
- procedures for expedited service planning when crisis or urgent need is identified; and
- the individual’s signature.
PA-CM 4.02
- directly provide, or arrange for necessary services;
- provide case coordination and monitoring of services;
- ensure that they receive appropriate advocacy support;
- assist with access to the full array of services to which they are eligible; and
- mediate barriers to services within the service delivery system.
- sensitivity to their needs and personal goals;
- a non-threatening manner;
- respect for their autonomy, confidentiality, sociocultural values, lifestyle choices, and complex family interactions;
- flexibility; and
- appropriate boundaries.
PA-CM 4.03
PA-CM 4.04
- confirmation, usually within one or two working days, that a service has been initiated as scheduled;
- verification, usually within 15 working days, that the service is appropriate and satisfactory;
- follow-up every three months; and
- immediate response to any complaints or problems that develop in the delivery of services or with the individual or family receiving services.
PA-CM 4.05
- service plan implementation;
- the individual’s or family’s progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of agreed upon service goals.
PA-CM 4.06
- review progress toward achievement of agreed upon service goals; and
- sign revisions to service goals and plans.
Case Management (PA-CM) 5: Intensive Case Management
Currently viewing: INTENSIVE CASE MANAGEMENT
VIEW THE STANDARDS
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-CM 5.01
- 24-hour crisis intervention;
- psychiatric services;
- housing services;
- medical and dental services;
- alcohol and other drug education and treatment;
- public assistance and income maintenance;
- family support services;
- vocational training and job placements; and
- transportation.
PA-CM 5.02
- initiating change agent activities;
- teaching problem solving skills; and
- modeling productive behaviors.
PA-CM 5.03
PA-CM 5.04
PA-CM 5.05
Case Management (PA-CM) 6: Case Closing and Aftercare
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
PA-CM 6.01
- is a clearly defined process that includes assignment of staff responsibility;
- begins at intake; and
- involves the worker, persons served, and others as appropriate to the needs and wishes of the consumer.
PA-CM 6.02
PA-CM 6.03
PA-CM 6.04
- 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
- conduct a formal case closing evaluation, including an assessment of unmet need, when the agency has an interagency agreement that does not include aftercare planning or follow-up.