Standards of Care Applying to Transitional Care Facilities Individualized Continuum Of Care Plan
- Client-Developed Continuum of Care Plan - Timeliness: Clients shall be assisted in initiating an individualized Continuum of Care Plan within twenty-four (24) hours of the completion of their comprehensive assessment of their current social, health and education/employment conditions and needs.
In the event that a client developed a Continuum of Care Plan while in the care of another provider, the primary care provider shall incorporate the client's Continuum of Care Plan into the primary care provider's service plan for the client, subject to revision by the client and his or her primary care case manager.
- Client Contract: The Continuum of Care Plan is an individualized contract based upon the participant's current state, capabilities and personal goals. The Continuum of Care Plan shall describe the participant's needs for supportive services and outline the steps that the participant must take in order to begin the personal process towards residential and financial stability and self-sufficiency. The client's signature on the Continuum of Care Plan signifies his or her commitment to obtaining residential, financial and personal stability and self-sufficiency.
- Basis of Individualized Continuum of Care Plan: The individualized Continuum of Care Plan shall be based on the comprehensive assessment of client's conditions and needs, as well as case management recommendations, and the client's personal goals and objectives. Goals and/or services sought by the client should be consistent with those articulated by the client during initial engagement and assessment by the Trust-coordinated Outreach, Assessment and Placement Program or while in the care of another provider.
- Potential Needs to be Reflected in Client's Goals and Objectives: The individualized Continuum of Care Plan should address the following goals and objectives that respond to the following potential needs: health (physical and mental health, including substance abuse), education, vocational skills and employability, benefits and/or benefits, housing, child care and legal services, as well as family/interpersonal issues and spirituality.
- Establish Realistic Goals: Unrealistic goals should be avoided to prevent discouragement with the rehabilitation process. Conversely, too simplistic goals should be discouraged to prevent loss of interest by the client due to the existence of too few challenges. The choices made by the client with the assistance of his or her case manager should be realistic and within the client's range of skills, abilities and present circumstances.
- Weekly Monitoring of Client Progress: The participant's progress in meeting goals set forth in the Continuum of Care Plan should be monitored on a weekly basis through weekly meetings with the client's case manager.
- Flexibility and Adjustment: Continuum of Care Plans are intended to be individualized, flexible service plans facilitating steady movement toward independent living at a pace suited to each participant's circumstances and needs. The Continuum of Care Plan must be adjusted to reflect progress or identified areas where additional attention is needed either by the client's own efforts or through the provision of additional services and/or resources.
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