RESPONSIBILITIES: I. ASSESSMENT
- Gather all necessary information regarding the person served in order to identify and document the person’s preferred lifestyle, strengths and needs.
- Coordinate and complete assessments as required for funding or other purposes.
- Participate in team meetings to assess and identify people’s needs and preferred lifestyle ensuring person centered discussions and decisions.
II. DEVELOPMENT OF SUPPORT PLAN
- Utilizing information collected through assessment, develop and keep current a Person Centered Support Plan to meet State requirements which specifies the goals and a course of action to address medical, social and educational needs and preferred lifestyle.
- Work with the person and their team to ensure the active participation of the person in the planning process.
III. REFERRAL ACTIVITIES
- Refer and link persons with medical, social, education and other programs which can meet the needs identified in the Person Centered Support Plan.
- Ensure informed choice by sharing information about community services, supports, resources and funding with person /guardians.
- Provide follow-up on referrals ensuring the person was able to access the resource and that the resource met the need.
- Facilitate transition processes by scheduling required Transition Meetings and completing Transition Plans making sure necessary information is shared for a successful transition.
IV. MONITORING AND FOLLOW UP
- Maintain minimum contact standards to build relationships, identify unmet needs and ensure services in the person’s Person-Centered Support Plan are adequate and provided as indicated. Monthly contact for persons receiving Day and Residential Services and quarterly contact for all others.
- When there are changes in the needs or status of the person, make adjustments to the Person Centered Support Plan and service arrangements with providers.
- Provide follow up and documentation for issues involving abuse, neglect, exploitation, medical urgencies, injuries or involvement with criminal justice system.
V. DOCUMENTATION AND RECORDS
- Develop and maintain individual records according to divisional and State procedures to meet licensing standards.
- Maintain daily documentation of Targeted Case Management activities according to State requirements.
- Meet Case Management Division minimum performance expectations by providing documentation of providing an average of 400 units per month of TCM activities.
VI. CASE MANAGEMENT TEAM
- Actively participate in divisional team meetings by sharing ideas, brainstorming and assisting team members to improve quality of services provided.
- Act as a resource and support for other team members and provide coverage when necessary.
- Provide input on division goals, training needs and other team issues.
- Maintain professional relationships and effective communication with support systems and service providers on behalf of person/family and TARC.
- Participate in the annual Case Management events.
VII. OTHER DUTIES AS ASSIGNED