Ongoing Case Management and Monitoring Activities

Intent

Regional staff will undertake a variety of activities to ensure Individuals are able to access needed supports and services to be included in community life, be as independent as possible and to achieve their outcomes as identified in their PDD Outcome Plan.

Policy and Procedures

Case management activities enable regional staff to have ongoing contact and communication with the Individual and their family/guardian (if designated) to respond proactively and effectively to changes in an Individual's circumstances and evaluate the effectiveness of supports and services.  Ongoing case management activities will be planned, documented on the PDD Outcome Plan and completed with all Individuals receiving supports and services from the PDD Program.

Regional staff are required to complete a variety of activities as part of ongoing case management.  Specific case management activities and requirements are outlined in the following PDD program policies, including:

  • Information Sharing and Protection of Privacy;
  • Complex Service Needs;
  • Service Design and Planning;
  • Service Delivery – Community Service Provider;
  • Service Delivery – Family Managed Services;
  • Safeguards and Standards; and
  • Policy Exemptions (review).

These policies require regional staff to provide oversight, and review and monitor the effectiveness of specific services and supports to determine achievement of the Individual’s desired outcomes, as well as satisfaction with the supports and services they are receiving.

Ongoing case management activities include, but are not limited to:

Case Management Activity, regional staff will

Refer to Related PDD Policy Section:

As a member of the support team, identify and evaluate support strategies and achievement of goals and outcomes

Service Design and Planning: minimum annual requirement with interim meetings as required.

Review of Individual Support Plans (ISP)

Service Design and Planning: minimum annual requirement, or with each ISP update.

Monitor and review behavioural support plans (if required)

Complex Service Needs: as per PDD Outcome Plan

Confirm completion of specialized staff training (if required)

Complex Service Needs: as per PDD Outcome Plan

Participate, review and monitoring of risks assessment and risk management strategies (if required)

Complex Service Needs: as per PDD Outcome Plan

Review and/or adjustment of PDD services

Service Design and Planning: minimum annual requirement

Complete other identified case management activities

 

As part of each case management activity, regional staff will:

  • ensure a full understanding of the Individual’s needs and circumstances (see Service Design and Planning);
  • consider preventive measures to reduce risks associated with the potential for abuse, ensure opportunities for a good quality of life; and
  • assist the Individual to be included in all discussions and decision making about their individual outcomes.

All activities related to planning, development of Individual Support Plans and meetings of the support team to review Individual Support Plans must include the Individual and guardian (if designated).

Ongoing case management activities can involve a variety of contact methods, including face to face meetings, phone contact and email exchanges with the Individual and their support network, and attendance at case conferences and planning meetings.

Documentation of Case Management Activities

Regional staff will document all activities related to ongoing case management in CSS – Notes, and track planned activities utilizing CSS – To Do Items. All information and decisions resulting from ongoing case management activities will be documented using the CSS-Notes description conventions to ensure reliable access to the information.

Documentation of activities will concisely and objectively describe any evidence and/or information gathered to support decisions, conclusions or to inform ongoing case management activities.

The information (documents) received during ongoing case management activities relevant to the health and safety of the Individual or their caregivers will be documented on the Health and Safety Document Summary, for example, risk assessments.

Regional staff will complete CSS – Notes using the description conventions as listed in the CSS- Notes description resource. The information contained in the note must minimally address each of the listed items. Ongoing case management activities that are planned as a result of these contacts will be tracked in CSS - To Do Items.

Unable to contact Individual and/or guardian (if designated)

In circumstances where the regional staff is unable to contact the Individual and/or guardian (if designated) to complete regular monitoring and/or service planning activities, regional staff will intensify efforts to make contact.  After three attempts within a three week period, staff will consult with their supervisor regarding next steps, which may include attempting contact up to once every day for five consecutive days.

If no contact has been made after this series of contact attempts, regional staff will consult with their supervisor regarding the need to report the concern. The decision to report will be based on the Individual’s unique circumstances (i.e. regional staff is aware of risks within the Individuals’ current living situation, whether they have complex needs, if the Individual is engaged in a high risk lifestyle, etc.)  All attempts to re-establish contact will be clearly documented in CSS - Notes.

If at any time, regional staff become aware of situations where Individuals may be at risk of abuse or where there are health and safety concerns, regional staff have an obligation to report and/or take action (see Safeguards and Standards – General) immediately and must follow the processes outlined in the Abuse Prevention and Response Protocol.

PDD will work with the Individual’s support network, including family, service providers and others, as appropriate, to re-establish contact to ensure the Individuals safety and well-being.

If the Individual who cannot be contacted is actively receiving services from a PDD service provider, regional staff will:

  • Review the written update submitted by the service provider and/or FMS Administrator
  • Contact the service provider(s) and/or FMS Administrator for confirmation of involvement with PDD services and the Individual’s regular participation
  • If the individual is no longer participating in PDD services, regional staff will complete the process for individuals not accessing PDD services (below)
  • If the individual is accessing PDD services, contact the service provider and/or FMS Administrator to confirm contact information and attempt (second time) to contact the Individual and/or guardian (if designated) directly.
  • If contact is not re-established by directly contacting the Individual and/or guardian (if designated), arrange to meet with the Individual at the service provider and/or FMS Administrator site (e.g. at the Individual's residence/group home).

If the Individual is in the process of eligibility determination for the PDD program, participating in service design and planning or is not currently receiving PDD funded services for some other reason, staff will:

  • Attempt to establish contact via phone or email indicating there is a requirement for PDD to maintain contact with Individuals and/or guardians (if designated); and.
  • Consult with other Government of Alberta programs that the Individual may be accessing, such as Assured Income for the Severely Handicapped (AISH), Office of the Public Guardian and Trustee (OPGT), Children’s Services, to request assistance in contacting the Individual.

If contact is not established, regional staff will consult with their supervisor to determine next steps:

  • When there are indicators (isolation, conflict in the home, unstable housing arrangement, drug or alcohol abuse suspected (Individual or caregivers), inconsistent access to basic needs (e.g. food) that the Individual’s or caregivers safety may be at risk, supervisor and regional staff will determine the most appropriate response:
    • attempt to establish contact through a home visit at which a meeting time/place will be set, and/or;
    • request RCMP or local police force, to complete a safety check.
  • Attempt to establish contact with the Individual and/or guardian (if designated) by mailing a letter requesting contact within 30 days.

If contact is still not established, within a reasonable period of time based on knowledge of the Individual and their circumstances, regional staff will:

  • attempt to establish contact through a home visit at which a meeting time/place will be set, and/or;
  • request RCMP or local police force to complete a safety check if there are concerns for their health and safety.

If the above measures have not resulted in re-establishing contact and activities have been completed to mitigate concerns related to the immediate health and safety of the Individual (i.e. contacting other program areas, family, service providers and police), regional staff will continue their efforts to re-established contact with the Individual and/or their guardian (if designated) by undertaking the following ongoing activities until regional staff have re-established contact:

  • Attempting to establish contact via phone or email (minimally every three months);
  • Consulting with other Government of Alberta programs that the Individual may be accessing, such as Assured Income for the Severely Handicapped (AISH), Office of the Public Guardian and Trustee (OPGT), Children’s Services, to request assistance in contacting the Individual (periodic check in); and
  • Checking with other Community and Social Service programs for involvement (AISH, Alberta Supports) using Mobius (ongoing);
  • Contacting former service providers and/or other community resources previous accessed by the Individual (periodic check in); and
  • Checking community resources, such as Vulnerable Persons Registry (minimally every three months).

All attempts to re-establish contact will be clearly documented in CSS – Notes, using the CSS – Notes description conventions.

An Individual’s file will not be closed due to inability to contact the Individual and/or guardian (if designated)  (see File Closure).

Legislative Authority

Created: 2018-04-12
Modified:
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