A. Definition: Assistance either in the form of access or care coordination in circumstances where the older person and/or their caregivers are experiencing diminished functioning capacities, personal conditions or other characteristics which require the provision of services by formal service providers.

B. Service Activities Minimally Include:

* Case Finding Activities: The identification of individuals for intake.

* Intake: Through the administration of a defined intake process developed or approved by the Area Agency on Aging, an individual with potential case management needs as defined below shall be identified

1. An individual must be age 60 or older; and

2. An individual must demonstrate a need which requires development of a coordinated case plan, follow-up, and/or advocacy; and/or

3. An individual has multiple or complex problems which are often chronic in nature and which may affect the ability of that individual to live independently; and/or

4. An individual has potential need for multiple services; and/or

5. An individual has presented problems which are vague or ill-defined; and/or

6. An individual has insufficient informal supports to care for his/her needs.

* Needs Assessment: A face-to-face comprehensive assessment, preferably conducted in the home or place of residence of the client, must be conducted for each Title III case management client utilizing a standardized tool, developed or approved by the Area Agency, to evaluate the conditions of the client and to identify goal oriented needs for services and/or problems needing resolution.

* Case Plan Development: A written plan of care shall be prepared for each client utilizing appropriate and available formal and informal resources, using a standardized form developed or approved by the Area Agency on Aging. The case plan shall identify available services and problem solving efforts to meet the client's determined needs and to enable the client to live with maximum possible independence. A copy of the case plan shall be given to the client and/or client's family and/or significant individual, and so documented in the client's file.

* Case Plan Implementation: A referral of the applicant/client to an appropriate resource for service provision and/or problem resolution shall be made and documented in the applicant's/client's file. If the referral is made to an informal network (family, friends, etc.), the service and/or problem-solving arrangement agreed to regarding duties and responsibilities shall be documented in the client's case plan. The following activities shall be performed for each client, as appropriate and needed:

1. Active intervention and advocacy on behalf of the client to access necessary services from community organizations and to resolve problems experienced by the client;

2. Establishment of linkages with service providers for the prompt and effective delivery of services needed by the client, including submission of instructions for service delivery to the appropriate service providers; and

3. Encouragement of informal care given by individuals, family, friends, neighbors, and community organizations, so that publicly supported services supplement rather than supplant the roles and responsibilities of these natural support systems.

* Review and Evaluation of Client Status:

1. Follow-up: Periodic monitoring shall be conducted through telephone or face-to-face contact to ensure prompt and effective service delivery and response to changes in the client's needs and status. All follow-up shall be documented in the client's file.

2. Reassessment: A face-to-face reassessment of the client's condition and needs must be conducted, preferably in the home of the client, no later than the 12th month from the last completed (re)assessment, or more frequently as dictated by change in the client's circumstance.

* Case Closure: Case closure shall occur in the following instances.

1. Death of the client;

2. Relocation out of the geographic service area;

3. Client cannot be located;

4. Client is hospitalized, enters a group care facility, is institutionalized or is not available for services for more than ninety consecutive calendar days;

5. Client is no longer in need of case management services because of changes in the client's condition or circumstances;

6. Client refuses services;

7. Client requests termination; or

8. Client refuses to cooperate in the provision of case management services.

C. Unit of Service: One hour of staff time expended in behalf of a client constitutes one unit of service.

D. Case Management Award & Organizational Standards:

Refer to Ill. Adm. Code 220.600

E. Case Management Service Standards

1. The Area Agency on Aging shall assure that each case management service provider has a resource/service directory that includes case management services as well as other community based long term care services available within their service area, and has access to information on resources outside of the service area. The Area Agency on Aging should assure that the resource/service directory is kept current, including a mechanism for exchanging updated information.

2. The Area Agency on Aging shall assure that each case management service provider has a procedure for how it gives objective information to clients on their options for services and resources available.

3. The Area Agency on Aging should develop and implement a process for case management service providers to provide information to the Area Agency on Aging about gaps in services.

4. The Area Agency shall define the Title III client population for case management services, including the target population for service provision and eligibility requirements (if applicable).

5. Client contribution/donation procedures for case management services must be clearly delineated. Client contribution/donations may not be solicited for any CCP activity.

6. The Area Agency on Aging must outline the responsibility of case management service providers for the completion of assessments for Title III home delivered meals and the payment for this function, if applicable. The relationship between each case management service provider and appropriate Title III home delivered meal providers should also be outlined by the Area Agency on Aging.

7. Case management supervisors and case managers must meet the education and experience standards contained in 89 Ill. Adm. Code 220.605.