Adult Case Management
Intake and Admission
Customers are referred to Case Management Services by Access clinicians, the hospital liaison, outpatient therapists, and case managers from other programs. The Case Management Services Program serves adults with mental illness who are at risk of psychiatric hospitalization due to their serious and persistent mental illness, and who need help accessing needed mental health, medical, social, educational, and vocational services. Case Management serves individuals with a secondary problem of substance abuse, those dually diagnosed as Mentally Ill and Developmentally Disabled, and the medically fragile. When any special needs are identified, staff coordinates the service plan with appropriate professionals.
Admission criteria for MI Community Case Management include:
- Van Buren County resident.
- Eighteen years of age or older.
- Mentally ill adults that meet diagnostic criteria from DSM-IV-R or ICD-9-CM,and the primary presenting problem is not due to a developmental disability or substance abuse.
- Customer lacks capacity for independently accessing and sustaining involvement with needed services.
- Customer is willing to accept or is court ordered to comply with case management services.
- Assessment indicates functionally limited customer with multiple needs or a high level of vulnerability.
- Customer needs access to the continuum of mental health services.
The Access Department prior to referral to Case Management Services completes a comprehensive psychosocial assessment for all customers. The assigned case manager will complete a comprehensive psychosocial/case management needs assessment as necessary, but no less than annually, thereafter. The assessment shall include the customer’s assets, deficits, and needs in the following domains:
- Health and physical condition
- Basic self-care
- Daily living skills
- Community living skills
- Social, interpersonal, emotional and intellectual functioning
- Educational and vocation al skills
- Leisure/recreational abilities
- Legal/financial needs
Customers may also be referred for other assessments, e.g., nursing, psychological testing, occupational therapy, as needed. Identified needs of the customer will result in a service recommendation and included in the master treatment plan. Appropriate referrals will be made to meet customer needs should the assessment reveal the person does not need case management services. All services are provided in compliance with Department of Community Health guideline on person centered planning.
Linking and coordinating services for the customer, including referrals within Van Buren CMH and to community agencies, is an essential programming component of case management. All referrals are discussed with the customer to allow him/her to make an informed choice. Releases of Information are obtained prior to any referral being made to an outside agency.
The Michigan Department of Community Health defines the four core elements of case management as assessment, service plan development, linking and coordination, monitoring of services , and advocacy . Case managers assist customers in gaining access to mental health, medical, social, educational, and other services as needed. Case managers provide support services as well as organize other resources to help support the customer by assisting the customer, as much as possible, to use and maintain supports within the community while encouraging the greatest degree of independence possible for the customer. Case managers are ready to intervene and assist whenever more help is needed.
Adults with serious and persistent mental illness can avoid many problems if deterioration in the condition is noticed as soon as possible. Case managers identify with each customer those behaviors (called prodromals) that signal a deterioration in his/her condition so that early intervention can take place. These prodromals are recorded in the updated assessment and shared with significant others as appropriate.
The case manager is the customer’s advocate within the agency and in the community to assure services that enhance the customer’s personal growth and community adjustment. Case Management S ervices are provided on an outreach basis in the person’s residence, hospitals, shelters, medical and psychiatric service si t es, and at community sites such as restaurants as well as agency sites.
Case managers provide the linking and coordinating of crisis services as needed for their assigned customers. This includes helping the customer to problem solve about the crisis situation, providing emotional support, obtaining needed evaluations and interventions, and coordinating with inpatient services when needed.
Plan Development, Implementation and Management:
Case Management Services are guided by a written treatment plan which must be comprehensive and coordinate all services provided by Van Buren Community Mental Health. The development of the treatment plan is a collaborative process involving the customer, and persons of the customer’s choice.
Referral – Exit/Discharge and Follow-up
There are three criteria for exit from Case Management Services.
- The customer becomes able to access needed services appropriately and/or the need for services from Van Buren Community Mental Health is discontinued or the customer desires exit from services.
- The customer needs/requests less intensive or different services (e.g. transfers to FIA for monitoring, family physician, nursing medication monitoring services or outpatient therapy as the customer is able to access services appropriately).
- The customer needs more intensive services (e.g., transfer to the ACT teams STEPS or MI/CA