PURPOSE:
To initiate, facilitate, and perform a variety of casework related functions pertaining to the development and implementation of the integrated, person centered plan which encompasses all aspects of the participant’s life. The Case Manager is responsible for ensuring residents receive direct and indirect support across every aspect of their daily lives including: dignity, self-advocacy, and increased autonomy. The Case Manager is responsible for direct oversight and case management of family/individual cases and providing in home support coverage as necessary.
The Adult Residential Services Case Manager is the primary internal, service provider advocate for participants on their caseload in compliance with agency mission, program guidelines, best practices for individuals with ID/DD, applicable laws, rules/regulations, and policies and procedures promulgated through code agencies responsible for surveillance and regulatory oversight of Little City Foundation’s residential services. The Case Manager coordinates and leads the multidisciplinary team (ISC/ISSA, medical, clinical & behavioral, home & day program management, parent/guardian) through the collaboration process to meet the needs of individual’s served including but not limited to: design, implementation, and monitoring of implementation strategies used to meet quality of life outcomes indicated in person centered plan(s), completion of required assessments and required paperwork, oversight of the delivery of services provided across day and home environments, and evaluating whether services provided and recommended continue to be appropriate across settings.
The Adult Residential Services Case Manager maintains accountability for the upkeep of participant files on their caseload and ensures the delivery and/or coordination of all residential services are in compliance and accordance with policies and procedures promulgated through agencies responsible for surveillance and regulatory oversight of Little City Foundation’s residential services including: BALC, DPH, DHS Rules 115 and 116, HCBS, CARF, HUD, & any other entity to which the adult residential programs maintain accountability.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
The list of essential duties and responsibilities, as outlined herein, is intended to be representative of the task to be performed. The omission of an essential function does not preclude management from assigning duties not listed herein is such duties are a logical assignment to the position.
Person Centered Planning, Advocacy & Implementation
Carries an average caseload of up to 40 adults receiving residential services in a variety of potential living arrangements. Serves as primary service provider advocate to participants including: services and supports needed to help the person achieve their goals, promotion of and teaching self-advocacy, assuring individual(s) participate in all decisions affecting his/her life to the greatest extent possible. Responsible for monitoring the health, safety, well-being and satisfaction of each person served, and conducts on-site visits to short/long-term rehabilitation facilities as well as hospitals where applicable. Additionally, transports residents to/from and advocates at medical appointments when necessary. Serves as primary contact person for guardians, interdisciplinary team members, and all outside service providers. Conducts at least bi-weekly visits with each assigned adult in his/her residential home(s) and at least monthly visit in his/her day program to ensure appropriate services are implemented. Collaborates with the interdisciplinary team (IDT) in developing and implementing the following: Ensures all interdisciplinary team members are invited to all meetings, including but not limited to: 30-Day Person Centered Plan (PCP) for new admissions, annual PCP review, any subsequent IDT meeting needed prior to annual PCP review, hospitalization/rehabilitation discharge planning, LCF discharge. Completes implementation strategies for outcomes written by ISC within 20 days of receiving parent/guardian approved PCPs and documents implementation strategy approval attempts (3 minimum). Participates in communication, collaboration, and team meetings with all centralized support teams to ensure the coordination of service delivery, assurance of program quality, and integrate subsequent objectives into the person centered plan. Completes Mental Health Assessment for all individuals served with primary mental health diagnoses (SLOF), including quarterly and six-month reports. Attends all psychiatric appointments for individuals on their caseload and ensures required paperwork is complete/provided. When appropriate, attends IEP meetings for young adults still served by Illinois State Board of Education approved programs. The Case Manager maintains overall accountability for initial and ongoing training of implementation strategies for participants on their caseload, essential duties include: Ensuring implementation strategy objectives written are specific, measurable, achievable, realistic, and time oriented (SMART). Providing clear and concise, step-by-step instructions for implementation by direct care staff. Providing all home staff with initial training on implementation strategies, and additional training as requested by home management. Maintains documentation of training for all direct care staff. Attends monthly team meetings for homes where participants on their caseload reside, as requested. Runs reports and monitors participant progress toward achieving objectives at least monthly and adjusts implementation strategies accordingly, providing retraining as necessary. Communicates staff performance concerns directly to the home manager as needed.
Programming & Quality Assurance
Completion of required paperwork, including but not limited to:annual consents/releases and subsequent medical provider consents/releases, implementation strategies across home/day program(s), medical and psychiatric provider reports/appointment paperwork as needed.
Ensuring participant demographic information (state identification, social security card, current and emergency contacts, and face sheet photo), current psychological (within 10 years), annual person centered plan & discover tool, & behavior service plan (annual) are present in the clinical file. Completion of monthly Q note detailing participant progress toward achieving outcomes/objectives, community integration, summary of monthly services provided, assessment of appropriateness of services provided, and medical appointments attended. The Case Manager is also responsible for providing this information to the respective ISC agency as well as parent/guardian. Completion of DHS related assessment & paperwork that assures continuous appropriate placement including but not limited to: annual ICAP, turnaround form, nightly participant absences, nightly absences reports & subsequent bed hold extension requests, & STAR form as needed. When applicable, works in conjunction with the home manager for implementation and coordination of family/friend home visits. Completion of Home without Supervision Assessment and indirect skill and behavioral assessment(s) as needed. Documentation of collateral and direct participant contacts via appropriate progress note(s). Completion of internal/external service referrals as needed. Participation in internal and external file review, upon request & in compliance with HIPAA. The case manager participates in rotating Case Manager On-Call responsibilities, including after hours and weekend on-call for emergency medical treatment and notification of unusual incidents as needed per agency policy (including 24/7 emergency coverage as needed).
ARS Department & Inter-Department Collaboration
Upon request, the Case Manager produces files and paperwork requested by internal & external department team members as relevant to the interdisciplinary team within a reasonable amount of time. Where applicable, the Case Manager assists members of the IDT team in obtaining additional documentation from parents/guardians and ISC personnel. Where applicable, the Case Manager assists members of the finance department in obtaining financial information and required documentation from the case/home management team (eg. HUD, monthly/quarterly bank statements, etc). Where applicable, the Case Manager works collaboratively with the Intake Coordinator to provide documentation required for intake, billing, DDD program eligibility & transfer.