Section .0100 ‑ Scope Of Service

Link to law: http://reports.oah.state.nc.us/ncac/title 10a - health and human services/chapter 06 - aging - programs operations/subchapter d/subchapter d rules.html
Published: 2015

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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.