- The Case Manager responsibilities include but is not limited to the following:
- Comply with all rules, regulations, policies and procedures of the agency and Vermont’s HCBS Eligibility and Enrollment Processes.
- Have experience with the Department’s state statutes, state rules, definitions, program requirements, program specific services, variances and exceptions.
- Engaging in assessment and planning activities for the individual’s services which includes but it not limited to:
- Assist and support the individual to understand the goals and activities of the individual-centered planning process, including assessment.
- Facilitate and schedule participation in individual-centered planning and assessment as needed.
- Complete Needs Assessment Annual Review Protocol once a year with the individual and their team.
- Assist the individual in discovery and exploration discussions, identifying preferences, strengths, goals and dreams, and needs in preparation for individual-centered planning process.
- Facilitate the completion of the DS Budget and Service Planning Context Document.
- Facilitate the completion of any additional assessments and gathering of documentation as needed, and ensure this information is available for the individual-centered planning process.
- Assist the individual to invite people of their choice (excluding legally prohibited individuals) to participate in the Individual Services Agreement (ISA) planning meetings to occur at times and in locations selected by and convenient for the individual.
- Work with the individual to develop agenda(s) and follow up notes for individual-centered planning meetings and ensure this information is distributed to members of the support team as approved by the individual.
- Support the individual to lead, and provide assistance as needed, throughout the individual- centered planning process.
- Assist the individual and their support team in identifying any needed modifications to the rights and freedoms afforded by the federal Medicaid HCBS requirements based on a documented health and safety need, and ensure that any such modifications are appropriately agreed upon by the individual and their guardian (if they have one) and documented in the ISA/BIP, including a plan for data collection and review of the modification.
- Review and updating of the individual-centered service ISA and related documents (including assessments), at minimum annually, with the individual.
- Provide the individual with information on self-direction opportunities, including the potential benefits, responsibilities and risks associated with self-directing services, during the planning process and upon request.
- Provide information to the individual on complaints, grievance and appeals rights, explain what these processes entail, and offer referrals to third-party assisters (such as Vermont Legal Aid and Disability Rights Vermont) when needed or upon request.
- Provide accessible information in the preferred method and language of the individual about individual rights and responsibilities annually and upon request.
- Coordinate meetings for the individual with other people receiving services from the providers under consideration who would be willing to give consent to share their experiences about those providers, as requested.
- Communicate the service authorization status to service plan team members, as appropriate.
- Make referrals to providers and provide follow-up assistance.
| - Identifying and linking to supports activities including but not limited to:
- Link the service and support needs of the individual with resources in the community which includes researching existing and identifying new resources in the community that may help individuals achieve the goals of their plans.
- Inform individuals about the use of unpaid, informal, generic, and specialized home and community-based services and supports that are necessary to address the identified needs of the individual and to achieve the outcomes specified in the ISA/BIP.
- Assist the individual in identifying and choosing service provider agencies and self- direction options to meet their needs and achieve the outcomes specified in the individual- centered service plan.
- When the regional Designated Agency (DA/)/Specialized Service Agency (SSA/)/Brain Injury Program (BIP) provider is unable to provide necessary services directly, collaborate with DA/SSA/BIP provider to refer to another DA/SSA/BIP provider or identify subcontracted service options and authorize the use of specific subcontractors and subcontracted services in compliance with relevant guidelines and policies.
| - Coordinating and Monitoring activities including but not limited to:
- Coordinate individual-centered service plan implementation with the individual and their support team (including family members, guardians when applicable, providers, resources and programs) to ensure all areas of the individual’s needs, preferences and outcomes as specified in the ISA/BIP are addressed.
- Support collaboration with people, organizations and resources that are important to the individual and necessary for the achievement of their goals and outcomes.
- Ensure that necessary documents and records are available and distributed to the support team, including the individual and their guardian (if they have one), family members, providers and natural support as the individual chooses or as required.
- As needed, coordinate and facilitate meetings between the individual and their DA/SSA/BIP provider, subcontractors, and/or self-directed employees to discuss the delivery of services.
- Assist in problem-solving and the resolution of barriers to receipt of services and supports, or barriers to accomplishments of outcomes specified in the ISA /BIP.
- Assist with the transition to the self-direction service delivery model if the is interested and ensure continuity of services during transition.
- Ensure that individuals are receiving the support they need as specified in the ISA/ BIP, when they need it, in order to see measurable improvements in their lives.
- Monitor the ISSA implementation, satisfaction, and health and well-being through visits with the individual and review of documentation, and through engagement with their guardian (if they have one), family members as applicable, and their service providers.
- Review, assess and respond to emergency situations and incidents and assure that actions taken are appropriate and timely to protect the health and welfare of individuals.
- Validate that services provided are consistent with the ISA/ BIP, and the needs and desired outcomes.
- Review individual progress on outcomes and initiate individual-centered team discussions or meetings when services are not achieving desired outcomes.
- Monitor the individual’s satisfaction with services, as well as the satisfaction of family members and guardians as applicable.
- Arrange for changes in services as necessary to address the needs or preferences of the individual and modify the ISA /BIP accordingly.
- Advocate for continuity of services, system flexibility and community integration, proper utilization of resources, accessibility, and rights.
- Participate in activities related to quality monitoring and reporting as required by the State.
| - Self-Direction Process: The Case Manager must provide information to the individual about the ability to self-direct their services and supports. Complete Employer of Record Assessment Tool to determine individual and/or identified surrogate’s capacity to perform employer responsibilities and level of support to be successful. If determined appropriate for the individual or surrogate to self-direct some or all direct services, the Case Manager will provide information related to support brokering services to determine if inclusion in the ISA and support the individual in finding a support broker that will meet their needs
| - Individual-Centered Planning: The Case Manager must support the individual in understanding the goals and activities of the individual-centered planning (ISA) process. Case Managers must guide individuals through an exploration and discovery process to determine preferences, interests, abilities, preferred environments, activities and supports desired by the individual. The Case Manager must facilitate conversations with family, guardians, and other individuals identified by the individual to provide additional information in support of the exploration and discovery process. The Case Manager must assist the individual in choosing, inviting and scheduling people to be part of the individual- centered planning team. The Case Manager must support the individual in developing the agenda, follow-up notes for individual-centered planning meetings, and ensuring that information is distributed to members of the support team approved by the individual. The Case Manager must support the individual in leading, and help as needed, through the individual-centered planning process.
| - For DS, the Case Manager must complete a contextual factors screening, currently under development, to determine if additional support or budget is needed beyond the budget range determined during the needs assessment process.
| - Services Identification:
- For DS, the Case Manager is responsible for collaborating with the DA, SSA and other service providers within the region to determine service availability and facilitate provider matching.
- For BIP, the Case Manager is responsible for identifying services available and facilitating provider matching.
| - HCBS Service Authorization Process:
- For DS, the Case Manager must gather and send all necessary information for service authorization including but not limited to, completed needs assessment, context assessment, individual-centered service plan, and accompanying service authorization request, to the State for reporting purposes only.
- For BIP, the Case Manager uploads the needs assessment, ISA, and accompanying service authorization requests, to the shared electronic record system.
| - Budget Exceptions:
- For DS, the Case Manager must initiate the exception process to request additional funding above the budget range determined through the needs assessment.
- For BIP, if the Case Manager identifies that the current services and supports are not meeting the individual’s needs, the Case Manager will submit to the State a request for a change to the service authorization with supporting documentation.
| - Monitoring, Follow Up, and Redetermination Responsibilities:
- For DS, the Case Manager must schedule progress meetings with individuals ensuring the individual-centered service plan is implemented while tracking and documenting individual’s health, wellbeing, needs, service goal progress and outcomes by receiving regular updates from direct service providers. At minimum, the Case Manager must review quarterly utilization data compared to plan budget and identify discrepancies that may need revisions to the plan. The Case Manager must update the individual-centered service plan based on revisions agreed to by the individual, their chosen circle of support, and the support team.
- For BIP, the Case Manager must schedule progress meetings with individuals ensuring ISA is implemented while tracking and documenting individual’s health, wellbeing, needs, service goal progress and outcomes by receiving regular updates from direct service providers. The Case Manager must update the ISA based on revisions agreed to by the individual, their chosen circle of support, and the support team.
- The Case Manager must provide records and information supporting the redetermination process to be conducted by the State or a contracted entity including records from direct service providers. The State or a contracted entity will review the information and arrange for any evaluations and assessments needed to support eligibility. The Case Manager must provide service choice counseling throughout the reassessment, individual-centered planning and service planning discussions.
| - Completing the Annual Review Protocol:
- For DS, annually, or more often if a significant change in need occurs, the Case Manager will be responsible for completing the annual review of needs with the individual and their team to ensure that any changes in needs are identified and addressed. If a significant change in need is identified, the individual may request a new needs assessment be completed. The Case Manager must arrange for the new needs assessment. At a minimum, the Case Manager must ensure a new needs assessment is completed every three years.
- For BIP, The Case Manager tracks when individuals are due for reassessment and initiates the process. The Case Manager reaches out to the individual/family and anyone else identified by the individual to schedule the reassessment. The Case Manager reviews the prior needs assessment, the ISA, case notes, and services plan in preparation for the reassessment. For every reassessment, the Case Manager updates the assessment tool, which may contain up to three years of assessment data. The Case Manager uploads the updated reassessment tool and proposed ISA to the electronic records system where it can be accessed by the State. The Case Manager must provide service choice counseling throughout the reassessment, individual-centered planning and service planning discussions. The State must conduct the reassessment review and may follow up with the Case Manager for any additional information or to communicate recommended changes prior to approval of the service plan. Finalized documents are housed in the Case Record.
- Write service notes indicating what actions were taken on behalf of the individual for each date of service.
- Utilize the periodic summary document developed by Columbus to document the progress of all outcomes for each individual served, including but not limited to Case Contact records/service notes (e.g., residential visit notes, monthly Case Management summaries, and outcome review of progress).
- Obtain approval of the summary by the QDDP for DS.
- Submit summaries in accordance with the frequency determined in the individual-centered service plan.
- Submit zero paid encounter data claims for each contact for data and reporting purposes only.
- Performs other duties related to the coordination and execution of proper care of the individual as assigned by the Case Manager Supervisor and State Program Administrator.
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