Primary Care Case Management

Case Management Services In General

The Mission and Purpose of primary care facilities is to provide housing and supportive services to special need populations comprised of persons with a history of mental illness or dehabilitating mental health conditions, including substance abuse, victims of domestic violence, HIV infection or AIDS, as well as homeless families in order to assist such persons in the transition from homelessness to independent living or to permanent supported housing, as the case may be.

• The Primary Purpose of Case Management Services is to integrate various internal and external service components into a coherent constellation of services tailored to meet the unique needs of individuals. Case Management shall be concerned with service coordination and problem solving in an attempt to insure appropriate service provision and continuity.
• Partnerships: The primary care facility shall develop partnerships with government, not-for-profit and community-based agencies or organizations or programs to coordinate and provide services to its clients.
• Case Managers: The case manager shall be responsible for producing a comprehensive or revised assessment, as the case may be, of the client's current social, health (including mental health and substance use/abuse) and education/employment conditions and needs. The case manager shall play a major role in assisting the resident in the development, or revision, and implementation of a Continuum of Care Plan which will enable the client to successfully achieve his or her personal goals and objectives by addressing unmet needs.
• Client Rapport: Development of a rapport between the client and his or her case manager, establishing trust and familiarity, is deemed integral to establishing an effective case management service plan and a realistic, client-developed Continuum of Care Plan.
• Scope of Case Management Services: The scope of case management services provided shall be client directed.

Core Case Management Functions

Core Functions of primary care facilities case management program should be:

• Assessment - a thorough evaluation detailing the client's current and potential strengths, weaknesses, service needs and appropriate resources to meet the service needs.
• Planning- the development of a holistic service plan with each client, containing service goals and appropriate timeliness.
• Linkage/Brokerage- the process of referring or transferring clients to all required internal and external services.
• Monitoring- the continuous evaluation of the client's progress, leading to reassessment and development of new service plans, linkages, or other dispositions as indicated.
• Advocacy- interceding on behalf of a client or group of clients to assure access to needed services and/or resources.

Areas of Case Management Intervention should include but are not limited to:

• Service Planning.
• Assistance in obtaining food and clothing and transportation.
• Referrals for in- or out- patient mental health services, substance abuse treatment, and medical services.
• Assistance in obtaining benefits.
• Provision and/or referrals to self-sufficiency related programs and services such as adult education, vocational training, job counseling, training and permanent placement services, child care and legal services and transportation.
• Assistance and referral to obtain appropriate housing placement in the Advanced Care level of the Continuum of Care, in the Dade County community or in the local affordable housing market.

Multi-Disciplinary Team Concept

Recommendation: It is recommended that primary care providers develop a multi-disciplinary approach towards providing care to the client to ensure an holistic response to the client's needs. Primary care providers are encouraged to develop multi-disciplinary care teams, comprised of the client's case manager, a health care worker caring for the client, and/or government or community providers directly serving the client, that would meet to review client progress, make recommendations and ensure successful referral to additional services and resources. Such approach ensures effective, comprehensive service provision as well as continuity of care as the client is placed with other housing programs within the Continuum or in the community.