Targeted Case Management Services

The vendor is required to provide case management program to serve adjudicated youth 30 days pre-release and 30 days post release.
- Targeted case management includes the following assistance:
•    Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. 
•    These assessment activities include:
o    Taking client history. 
o    Identifying the individual’s needs and completing related documentation; and 
o    Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual.
•    Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:
o    Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual. 
o    Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and 
o    Identifies a course of action to respond to the assessed needs of the eligible individual.
•    Referral and related activities, including referrals to appropriate care and services available in the geographic region of the home or residence of the eligible juvenile, where feasible (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including:
o    Activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and
•    Monitoring and follow-up activities are activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met:
o    Services are being furnished in accordance with the individual’s care plan. 
o    Services in the care plan are adequate; and 
o    Changes in the needs or status of the individual are reflected in the care plan.
•    Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.  
•    Frequency of additional monitoring:
o    Telephonic frequency: to be conducted according to each individual’s needs throughout the 30-day post-release period. 
o    In-person frequency: to be conducted according to each individual’s needs throughout the 30-day post-release period. 
o    Other: any other modalities most appropriate for each eligible juvenile, including virtual modalities. 
o    To be conducted according to each individual’s needs throughout the 30-day post release period.
•    Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual’s needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual’s needs. 
•    For instance, a case manager might also work with state children and youth agencies for children who are involved with the foster care system. 
•    If another case manager is involved upon release or for case management after the 30-day post release mandatory service period, states should ensure a warm hand off to transition case management and support continuity of care of needed services that are documented in the person-centered care plan. 
•    A warm handoff should include a meeting between the eligible juvenile, and both the pre-release and post-release case manager. 
•    It also should include a review of the person-centered care plan and next steps to ensure continuity of case management and follow-up as the eligible juvenile transitions into the community.
- Case records
•    Providers must maintain case records that document for all individuals receiving case management as follows: (i)the name of the individual; (ii) the dates of the case management services; (iii)the name of the provider agency (if relevant) and the person providing the case management service; (iv) the nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) whether the individual has declined services in the care plan; (vi) the need for, and occurrences of, coordination with other case managers; (vii) a timeline for obtaining needed services; (viii) a timeline for reevaluation of the plan.

- Contract Period/Term: 3 years