N.H. Admin. Code § He-E 805.05

Current through Register No. 50, December 12, 2024

Section He-E 805.05 - Required Case Management Services

(a) For each participant who selects or is assigned to a case management agency, the agency shall designate a case manager to provide case management services.

(b) The designated case manager shall conduct a comprehensive assessment of a participant within 15 working days of the date on which the agency receives department notification of the assignment, which shall:

(1) Utilize a formal assessment tool to evaluate the participant's status based on information gathered at a face-to-face meeting, and through other methods as needed; and

(2) Culminate in a written document that describes the participant's abilities and needs in the following areas:

a. Biopsychosocial history;

b. Functional ability, including activities of daily living and instrumental activities of daily living;

c. Living environment, including the participant's in-home mobility, accessibility, and safety;

d. Social environment, including social/informal relationships and supports, activities and interests, such as avocational and spiritual;

e. Self-awareness, or the degree to which the participant is aware of his or her own medical condition(s), treatment(s), and medication regime;

f. Risk, including the potential for abuse, neglect, or exploitation by self or others, as well as health, social or behavioral issues that may indicate a risk;

g. Legal status, including guardianship, legal system involvement, and availability of advance directives, such as durable power of attorney;

h. Community participation, including the participant's need or expressed desire to access specific resources, such as the library, educational programs, restaurants, shopping, and medical providers; and

i. Any other area identified by the participant as being important to his or her life.

(c) Within 20 working days of the date on which the agency receives BEAS notification of the assignment, the designated case manager shall develop a written comprehensive care plan for the participant, which shall:

(1) Be a person-centered agreement;

(2) Contain measurable objectives and goals, with timelines;

(3) Contain the following, based on the participant's needs as identified in the comprehensive assessment document and the MED needs list or support plan:

a. Paid services to be provided under medicaid or other funding sources, including:

1. The needs to be met by paid services;

2. Service costs;

3. Service funding source;

4. Provider names; and

5. The beginning and ending dates of each service, and the frequency of service provision;

b. Non-paid services or supports, including the needs to be met and the names of those individuals or groups providing such services or support;

c. Unfulfilled needs and gaps in services, including those that pose a risk to the participant's health and safety;

d. Any existing risks for abuse, neglect or exploitation, as defined in RSA 161-F:43;

e. A plan for mitigating any existing risks; and

f. An individualized contingency plan, as defined in He-E 805.02(l) ; and

(4) Be updated with written documentation as follows:

a. At least annually for as long as the participant is receiving CFI services;

b. Whenever changes occur in the participant's medical condition and/or in the participant's needs and desires; and

c. With progress notes reflecting each case management contact in (e) (1) below.

(d) The designated case manager shall monitor the services provided to a participant, as follows:

(1) Conduct the case management contacts required for each participant, as follows:

a. Case management contacts shall include no less than one monthly telephonic contact and one face-to-face contact every 60 days; and

b. Each case management contact shall be documented in a contact note;

(2) Ensure that services are adequate and appropriate for the participant's needs, and are being provided, as described in the comprehensive care plan;

(3) Ensure that the participant is actively engaging in the services described in the comprehensive care plan;

(4) Ensure that the participant is satisfied with the comprehensive care plan; and

(5) Identify any changes in the participant's condition, discuss these changes with the participant in order to determine whether changes to the comprehensive care plan are needed, and make changes to the comprehensive care plan as needed.

N.H. Admin. Code § He-E 805.05

#9242, eff 8-26-08

Amended by Volume XXXVI Number 36, Filed September 8, 2016, Proposed by #11167, Effective 8/25/2016, Expires 2/21/2017.

Amended by Volume XXXVII Number 10, Filed March 9, 2017, Proposed by #12115, Effective 2/22/2017, Expires 2/22/2027.