Case Management Services

The Vendor is required to provide transitional case management services to individuals who are over the age of sixty (60) or between the ages of eighteen (18) and sixty (60) with a chronic illness or disability, who meet Medicaid long term supports and services (LTSS) medical and financial eligibility criteria, are residing in qualified money follows the person (MFP) institution.
- Transitional case management services during business hours, 8:00 am to 5:00 pm, Monday through Friday.
- Pre-transition services
•    MFP transitional case management services from the department under this agreement unless the contractor notifies the department of a conflict of interest
•    Conduct and document a person-centered face-to-face comprehensive assessment of the MFP participant’s strengths and needs utilizing the MFP community transition assessment and plan provided by the department within fifteen (15) business days of receiving the initial referral, unless a later date is approved by the department.
•    MFP community transition assessment and plan in conjunction with the participant’s most recent minimum data set (MDS), medical eligibility assessment (mea) and preadmission screening and resident review (PASRR) to help inform the development of the initial care plan.
•    Risk identification and mitigation plan (RIMP) with the participant and use the information gathered to help inform completion of the participant’s contingency plan
•    Meet face-to-face, in person, with the participant twice monthly to discuss and provide transition coordination, which must include, but is not limited to:
o    Convening and facilitating person-centered service planning meetings.
o    Actively engaging and recruiting formal and informal support providers to participate in both the transition and service delivery.
o    Facilitating the transition from the institutional setting to community-based living.
o    Coordinating any other person-centered activities that are needed to support the participant’s transition to a community-based setting.
•    Assist the participant to connect with the following services at the participant’s request:
o    Medical services;
o    Behavioral health services;
o    Social, educational or other programs.
- Post transition services
•    Must monitor and document changes to the RIMP.
•    Must monitor and update contingency plan as needed.
•    Must assist the participant and the participant’s guardian or representative as necessary to access and maintain benefits for which they are eligible, including but not limited to:
o    Public benefits.
o    Medical benefits.
o    Financial benefits.
o    Specific grant programs.
•    Must continue to ensure home modifications, vehicle adaptations, and home cleaning and pest eradication are completed as needed and align with the RIMP and care plans.
•    Monitor utilization of services and follow up with the participant and rendering providers for any under or over utilization that is not in alignment with the care plan and develop recommendations to realign utilization with the documented service needs
•    Must continue to provide copies of care and contingency plans to the participant and distribute to care teams as agreed to by the participant
•    May be required to facilitate reviews of files conducted by the department on an annual basis, or as otherwise requested by the department, that may include, but are not limited to:
o    MFP participant case records. 
o    Records that pertain to staff training requirements and background checks under this agreement.