SUBCHAPTER 06D ‑ CARE MANAGEMENT
SECTION .0100 ‑ SCOPE OF SERVICE
10A NCAC 06D .0101 SCOPE OF CARE MANAGEMENT
Primary Service. Care Management is a coordinated care
function which incorporates case finding, assessment and reassessments,
negotiation, care plan development and implementation, monitoring, and advocacy
to assist functionally impaired older adults targeted in Rule .0103 of this
Section with obtaining the services necessary to be safely cared for within the
home and community setting.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. December 1, 1991.
10A NCAC 06D .0102 DEFINITIONS
As used in this Subchapter, the following terms shall have
the meanings specified:
(1) "Activities of daily living (ADL's)"
include eating, dressing, bathing, toileting, bowel and bladder control,
transfers, ambulation, and communication such as ability to express needs to
others through speech, written word, signing, gestures, or communication
devices.
(2) "Instrumental activities of daily living
(IADL's)" include meal preparation, medication intake, house cleaning,
money management, telephone use, laundering, reading, writing, transportation,
mobility, shopping, and going to necessary activities.
(3) "Case closure" means the discontinuation
of Care Management Services when the goals of the care plan have been met or
when the client is no longer eligible for Care Management Services.
(4) "Functionally impaired" means individuals
whose illness, disabilities, or social problems have reduced their ability to
perform self‑care and household tasks in an independent manner.
(5) "Complex care needs" means the presence
of significant impairments in activities of daily living or instrumental
activities of daily living, or both, with complicating mental, medical, social,
or behavioral problems, which necessitates professional intervention.
(6) "Review" means a regular contact by an
appropriate professional with the individual or family or both to note
progress, maintenance or deterioration, changes in circumstances, and adequacy
of the care plan in meeting the person's and family's needs, and to make any
needed adjustments.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. December 1, 1991.
10A NCAC 06D .0103 TARGET POPULATION
The target population consists of functionally impaired
older adults who are at risk of abuse, neglect, exploitation, or have complex
care needs, or both; and who, due to a critical time factor or the complexity
of services needed, are unable to access needed services in order to remain
safely at home.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. December 1, 1991.
SECTION .0200 ‑ SERVICE PROVISION
10A NCAC 06D .0201 CLIENT ELIGIBILITY
Care Management Services are limited to older adults 60
years of age or older and their spouses who meet the identified target
population.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. November 1, 1991.
10A NCAC 06D .0202 SCREENING
(a) Screening is a preliminary process used to determine if
an individual appears to belong in the target population.
(b) A screening instrument must be completed for each
person requesting Care Management Services.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. November 1, 1991.
10A NCAC 06D .0203 ASSESSMENT AND REASSESSMENT
(a) The assessment and reassessment are comprehensive
multidimensional methods used to determine the client's level of functioning
and confirm eligibility for Care Management Services.
(b) The initial assessment and all reassessments shall be
conducted in the client's home and shall address the mental, social,
environmental, economic, and physical health status of the client, as well as
the ability to perform activities of daily living (ADL's) and instrumental
activities of daily living (IADL's).
(c) The assessment and reassessment shall be conducted in
the client's home by a Social Worker and a Registered Nurse.
(d) A full reassessment shall be completed at least every
12 months or more frequently as the client's condition warrants, based upon
factors specified in Paragraph (b) of this Rule.
(e) The initial assessment and reassessments shall be
signed and dated by the Social Worker and the Registered Nurse and shall be
maintained in the client's file.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. December 1, 1991.
10A NCAC 06D .0204 CARE PLANNING
The purpose of the care plan is to identify the course of
action to be followed:
(1) Care plans for an eligible client shall be
developed within 12 working days of the initial screening.
(2) The care plan shall include, at a minimum, the
following information:
(a) Outcome oriented goal statements and
conditions for case closure;
(b) Both formal and informal services to be
provided;
(c) Agencies responsible for service provision;
(d) Frequency of service provision;
(e) Duration of service provision;
(f) Signature of the client or designated
representative indicating agreement with the care plan;
(g) Signature of the Registered Nurse and the
Social Worker developing the care plan;
(h) Date of care plan development.
(3) Care plans shall be reviewed at least quarterly or
more frequently as the client's condition warrants by both the Social Worker
and the Registered Nurse based upon factors specified in Rule .0203(b) of this
Section.
(4) All changes to the care plan must be documented and
dated on the care plan by the Social Worker and Registered Nurse, or both.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. December 1, 1991.
10A NCAC 06D .0205 MONITORING
The purpose of monitoring is to guarantee continuity of
services and to evaluate the client's continued eligibility for Care Management
Services:
(1) At a minimum, a monthly contact must be made to the
client.
(2) At least one contact per quarter must be conducted
in the client's home.
(3) All monitoring activities must be documented in the
client's file by the appropriate professional.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. November 1, 1991.
10A NCAC 06D .0206 DOCUMENTATION
Client records for Care Management Services shall include:
(1) A completed copy of the screening instrument;
(2) A completed copy of the initial assessment;
(3) Completed copies of all reassessments;
(4) Copies of the initial and any revised care plans;
(5) Documentation of all monitoring activities;
(6) Denial, termination or reduction of service when
appropriate;
(7) Documentation of client's approval for release of
information.
History Note: Authority G.S. 143B‑181.1(c); 143B‑181.10;
Eff. November 1, 1991.
