A Primer on Using Medicaid for People Experiencing Chronic Homelessness and Tenants in Permanent Supportive Housing. 5.3. Case Management


Services provided in PSH are often described as "case management," but Medicaid has its own set of requirements if the state seeks federal reimbursement for TCM state plan services. TCM services are separate from the rehabilitative services benefit. TCM services assist individuals in gaining access to needed medical, social, educational, and other services. A state that intends to target a certain population, such as persons who are experiencing homelessness, must meet all of the applicable TCM requirements including the service definition, requirements regarding the qualifications of the providers, and case records.68 TCM services do not include services that are an integral and inseparable part of another covered Medicaid service or activities that constitute the direct delivery of underlying medical, educational, social, or other services to which an individual has been referred.

TCM includes:
  • A comprehensive assessment.
  • Development of a specific care plan.
  • Referral and linkage activities.
  • Monitoring and follow-up activities.

TCM services begin with a "comprehensive assessment" of individual needs to determine the need for any medical, social, educational, and other services. This can include taking the client history and gathering information from other sources such as family members, medical providers, social workers, and others who are qualified to form a complete assessment of the individual. A comprehensive assessment could include information about the following:

  • Mental health symptoms and needs as presented in a diagnostic assessment;
  • Use of drugs and alcohol;
  • Vocational and educational functioning;
  • Social functioning, including the use of leisure time;
  • Interpersonal functioning, including relationships;
  • Self-care and independent living;
  • Medical and dental health;
  • Financial assistance needs;
  • Housing and transportation needs;
  • Current living conditions; and
  • Other needs and problems.

The next step is to "develop a specific care plan" that is based on the information collected through the assessment. The plan specifies goals and actions to address the medical, social, educational, and other services needed by the individual.

"Referral and linkage" activities may include the following:

  • Providing referrals to appropriate housing.

  • Communicating with a landlord on behalf of a client.

  • Monitoring service delivery through inter-agency consultation and communication, coordination, and referrals.

  • Helping clients understand the requirements of programs or services in which they are participating (including a housing program or other community resources) and monitoring a client's progress.

  • Assisting a client in making linkages to get needed services.

  • Coordinating with other agencies to obtain services for clients.

  • Coordinating with discharge planners to facilitate linkages to needed services for a person who is leaving a residential program or hospital.

  • Assisting a client to obtain health coverage for medical services.

  • Helping a person with linkages to transportation or child care needed to facilitate getting to medical appointments or gaining access to other needed services.

"Monitoring and follow-up activities" may include making contact with the individual, family members, and service providers to ensure that the care plan is implemented and adequately addresses the individual's needs. Related activities may include the following:

  • Regularly reviewing the written functional assessment.

  • Participating in case conferences to coordinate linkages to services.

  • Communicating routinely with the individual or other relevant people about the status of the individual or progress in achieving the goals of the service plan.

  • Conducting planning, assessment, record keeping, and documentation associated with service coordination.

  • Developing goals, service plans, written service agreements, and routine case supervisory activities, including receiving clinical supervision.

Case Management Arrangements
  • As TCM.
  • Through managed care organizations.
  • As part of HCBS.
  • Through Health Homes or other new care coordination/integration entities.

Case management services may also be offered as part of the care coordination functions of Medicaid managed care, or provided as part of the package of services offered by a health home, or as part of a package of HCBS provided through benefits established under Section 1915(i) of the Social Security Act or using a 1915(c) HCBS waiver. These are discussed later in this chapter and in Chapter 7.

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