Section 160. Utilization review of case management for recipients of auxiliary grants

A. Criteria of need for case management services. It shall be the responsibility of the assessor who identifies the individual's need for residential or assisted living in an adult care residence to assess the need for case management services. The case manager shall, at a minimum, update the assessment and make any necessary referrals for service as part of the case management annual visit. Case management services may be initiated at any time during the year that a need is identified.

B. Coverage limits. DMAS shall reimburse for one case management visit per year for every individual who receives an auxiliary grant. For individuals meeting the following ongoing case management criteria, DMAS shall reimburse for one case management visit per calendar quarter:

1. The individual needs the coordination of multiple services and the individual does not currently have support available that is willing to assist in the coordination of and access to services, and a referral to a formal or informal support system will not meet the individual's needs; or

2. The individual has an identified need in his physical environment, support system, financial resources, emotional or physical health which must be addressed to ensure the individual's health and welfare and other formal or informal supports have either been unsuccessful in their efforts or are unavailable to assist the individual in resolving the need.

C. Documentation requirements.

1. The update to the assessment shall be required annually regardless of whether the individual is authorized for ongoing case management.

2. A care plan and documentation of contacts must be maintained by the case manager for persons authorized for ongoing case management.

a. The care plan must be a standardized written description of the needs which cannot be met by the adult care residence and the resident-specific goals, objectives and time frames for completion. This care plan must be updated annually at the time of reassessment, including signature by both the resident and case manager.

b. The case manager shall provide ongoing monitoring and arrangement of services according to the care plan and must maintain documentation recording all contacts made with or on behalf of the resident.

Historical Notes

Derived from VR460-02-3.1300, §§ 12.1 through 12.3, eff. August 1, 1991; amended, Volume 10, Issue 16, eff. June 1, 1994; Volume 11, Issue 17, eff. July 1, 1995; Volume 12, Issue 16, eff. July 1, 1996.

Statutory Authority

§ 32.1-325 of the Code of Virginia and Item 396 E 5 of the 1995 Appropriations Act.