section .0200 – general case management
10a NCAC 25F .0201 CASE MGMT SVCS/ADULTS/CHILDREN AT‑RISK/ABUSE/
NEGLECT/ EXPLOITATION
(a) Case management is a set of interrelated activities
under which responsibility for locating, coordinating and monitoring appropriate
services for an individual rests with a specific person or organization. The
purpose of case management services for adults and children at‑risk of
abuse, neglect, or exploitation is to assist them in gaining access to needed
medical, social, educational, and other services; to encourage the use of cost‑effective
medical care by referrals to appropriate providers; and to discourage over‑utilization
of costly services. Case management services will provide necessary
coordination with providers of non‑medical services such as nutrition
programs like WIC or educational agencies, when services provided by these
entities are needed to enable the individual to benefit from programs for which
he or she is eligible. The set of interrelated activities are as follows:
(1) Evaluation of the client's individual
situation to determine the extent of or need for initial or continuing case
management services.
(2) Needs assessment and reassessment to
identify the service needs of the client.
(3) Development and implementation of an
individualized plan of care to meet the service needs of the client.
(4) Providing assistance to the client in
locating and referring him or her to providers or programs that can meet the
service needs.
(5) Coordinating delivery of services when
multiple providers or programs are involved in care provision.
(6) Monitoring and following‑up to ensure
services are received, adequate to meet the client's needs, and consistent with
good quality of care.
(b) The target group includes:
(1) Adults who are at‑risk or show
evidence of abuse, neglect, or exploitation as defined in G.S. 108A‑101.
Children who are at‑risk or show evidence of abuse or neglect as defined
in G.S. 7A‑517; and
(2) Who are Medicaid recipients; and
(3) Who are not institutionalized; and
(4) Who are not recipients of other Medicaid‑reimbursed
case management services provided through the State's home and community‑based
services waivers or the State Plan; and
(5) Who reside in counties providing the non‑Federal
matching funds to offer this service.
(c) The case manager shall determine whether an adult or
child is at‑risk of abuse, neglect, or exploitation as follows:
(1) At‑Risk Adult: An at‑risk
adult is an individual who is at least 18 years old, or an emancipated minor,
and meets one or more of the following criteria:
(A) An individual with only one consistent identified
caregiver, who needs personal assistance 24 hours per day with two or more of
the activities of daily living (bathing, dressing, grooming, toileting, transferring,
ambulating, eating, communicating); or
(B) An individual with no consistent identified
caregiver, who is unable to perform at least one of the activities of daily
living (bathing, dressing, grooming, toileting, transferring, ambulating, eating,
communicating); or
(C) An individual with no consistent identified
caregiver, who is unable to carry out instrumental activities of daily living
(managing financial affairs shopping, housekeeping, laundry, meal preparation,
using transportation, using a telephone, reading, writing); or
(D) An individual who was previously abused, neglected
or exploited, and the conditions leading to the previous incident continue to
exist; or
(E) An individual who is being abused, neglected, or
exploited and is in need of protection.
(2) At‑Risk Child: An at‑risk
child is an individual under 18 years of age who meets one or more of the
following criteria:
(A) A child with a chronic or severe physical or mental
condition whose parent(s) or caretaker(s) are unable or unwilling to meet the
child's care needs;
(B) A child whose parents are mentally or physically
impaired to the extent that there is a need for assistance with maintaining
family stability and preventing or remedying problems which may result in abuse
or neglect of the child; or
(C) A child of adolescent (under age 18) parents or
parents who had their first child when either parent was an adolescent and
there is a need for assistance with maintaining family stability, strengthening
individual support systems, and preventing or remedying problems which may
result in abuse or neglect of the child; or
(D) A child who was previously abused or neglected, and
the conditions leading to the previous incident continue to exist; or
(E) A child who is being abused or neglected and is in
need of protection.
(d) Enrollment of providers shall be accomplished in
accordance with section 1902(a) (23) of the Social Security Act.
(1) Case Manager Qualifications. Case managers
must meet the following qualifications:
(A) A case manager for at‑risk adults must:
(i) Have a Master of Social Work degree or a
Bachelor of Social Work degree, or be a social worker who meets State
requirements for Social Worker II classification; and
(ii) Have training in recognizing risk factors
related to abuse, neglect, or exploitation of elderly or disabled adults and in
assessment of functional capacity and needs related to activities of daily
living; and
(iii) Have experience in case management services for
elderly and disabled adults.
(B) A case manager for at‑risk children must:
(i) Have a Master of Social Work degree or a
Bachelor of Social Work degree, or be a social worker who meets State
requirements for Social Worker II classification; and
(ii) Have training in recognizing risk factors
related to abuse or neglect of children and in assessing family functioning;
and
(iii) Have experience in case management services for
children and their families.
(2) Provider Qualifications. Providers must
meet the following qualifications:
(A) Meet applicable State and Federal laws governing the
participation of providers in the Medicaid program.
(B) Be certified by the Division of Social Services as a
qualified case management provider. To be certified, a provider must:
(i) Have qualified case managers with supervision
provided by a supervisor who meets State requirements for Social Work
Supervisor I or Social Work Supervisor II classification.
(ii) Have the capability to access multi‑disciplinary
staff, when needed. For adults this includes, at a minimum, medical
professionals as needed and an adult protective services social worker meeting
the qualifications in Subparagraphs (d)(1)(A)(i) and (d)(1)(A)(ii) of this
Rule. For children, this must include medical professionals as needed and a
child protective services social worker meeting the qualifications in
Subparagraphs (d)(1)(B)(i) and (d)(1)(B)(ii) of this Rule.
(iii) Have experience as a legal guardian of persons
and property.
History Note: Authority G.S. 108A‑25(b); 108A‑54;
Social Security Act, 1915(g);
Eff. October 1, 1992;
Recodified from 10 NCAC 26B .0122 Eff. October 1, 1993;
Temporary Amendment Eff. January 9, 1997;
Recodified from 10 NCAC 26B .0123 Eff. January 1, 1998;
Amended Eff. August 1, 1998;
Transferred from 10A NCAC 22O .0123 Eff. May 1, 2012.