- Case management expectations
- Assessment should identify participant motivations, strengths, barriers and resources;
- Assessment and screening address the functioning of the whole family;
- All JOBS-eligible participants need to be offered learning needs, domestic violence, substance use disorder (SUD), mental health and physical health needs screenings;
- Participant assessment is ongoing, beginning with their first contact with the Department of Human Services (DHS) and continuing through changes in benefit programs and participant circumstances;
- Involve experts in assessing further participant needs if the screening indicates a need.
- Case plans are mutually developed between the participant and the family coach;
- Case plans are individualized to identify services that support each participant's self-sufficiency goals and are based on the participant's strengths, needs and abilities;
- Participants are provided information about available programs, resources and program requirements to support them in making informed choices about plan activities;
- Case staffings with the participant, branch team members and other partners can be used to ensure that the best thinking is available in plan development;
- Plans should be coordinated with other partners if those partners also have a case or service plan with the participants. (For example: child welfare, vocational rehabilitation, community action agencies, housing, etc.);
- All case plans are continually updated and evaluated based on participant need and using information from ongoing screenings and assessments;
- Participant contacts are frequent (at least monthly) and based on the needs of the client and case plan;
- All case plans reflect current participant abilities and the services they need to meet short- and long-term goals;
- Case plan, progress, strategies and resources should be documented in TRACS;
- Support service payments are made in a timely manner to support the participant's ability to engage intheir case plan.
Employment, self-sufficiency and wage enhancement focus
- All staff are responsible for helping families toward self-sufficiency;
- Previous work history, reasons for job loss and any criminal history concerns should be used to assess for appropriate employment related services;
- Factors that impact a participant's ability to maintain employment are addressed at the initial contact with participants , during job readiness activities and after participants go to work;
- Support is offered for working participants to enable them to retain jobs and enhance income.
- Decisions are made within program policy and intent;
- Program benefits are intended to support individuals and families temporarily as they increase self-sufficiency;
- Benefits are issued in a timely and accurate manner.
- Our participants are capable of making strides toward self-sufficiency;
- Our participants lead the development of their plans to become self-sufficient;
- Plans are based upon participant goals, strengths, barriers and resources;
- Our participants are accountable for their progress toward goals;
- Our services enable participants to become proactive so they learn to use resources to meet their own needs;
- The re-engagement process is used to reconnect the participant with their case plan goals and steps needed to address self-sufficiency, to establish whether the participant is able to complete their case plan and to address any barriers to participation;
- Disqualifications are used only when it has been established that the participant is willfully noncompliant.
- Case management is provided using the brokering concept, which means that we identify participant needs, assist participants in accessing services to address their needs and follow up on results of the referral and interactions with the service provider;
- Brokering includes collaboration with participants, other staff, partners and the community to provide services that ensure our participant's success;
- Participants are taught how to become their own broker so they may access services independently when needs arise;
- Program benefits are one of the resources we access when we broker for services;
- Our participants should be treated with the respect and dignity that honors their differences.
Meeting basic needs
- All staff are responsible for providing eligibility determination and benefit issuance in a timely and accurate manner;
- Ongoing eligibility processes are also opportunities for participant assessment and brokering for resources;
- The benefit determination and issuance process is integrated with the case management process; both support each other.
- Case management requirements
Case management includes assessing strengths and needs, developing a case plan and monitoring and supporting participant engagement to promote movement toward self-sufficiency.
|Definitions of Terms, Components, and Activities; JOBS, Pre-TANF, Post-TANF, TANF Rule
|461-001-0025 — Definitions of Terms, Components, and Activities; JOBS, Pre-TANF, Post-TANF, TANF
- Case management activities overview
Case management consists of the following primary activities:
- Screenings & Assessments include: the Employability Screening (DHS 7823A), the Family Assessment (DHS 7823C), Alcohol and drug and mental health screening (GAIN-SS), Learning Needs (DHS 421) and physical health;
All the interactions we have with DHS participants , from initial branch contact and screening, through intake and case management contacts. Initial screening for participant strengths, needs and goals is based on information gained from reviewing the Application for Services (DHS 415F) and Employability Screening (DHS 415A), as well as from the participant interview. The Family Assessment (DHS 7823C) is to be offered to participants by family coach within 90 days of TANF approval. The Family Assessment (DHS 7823C) may be conducted over a series of appointments or in one sitting. All branch staff and contractors with participant contact can contribute to assessment of participant needs based on their interactions with the participant. In all of these interactions, the goal is to help the participant identify which services are needed to support family self-sufficiency. Rapport and trust are built by helping participants identify and address their own issues;
- Brokering for resources, communication with partners, and case staffings, ensures that the most appropriate services are provided to the participant. Family coaches will work closely with community partners, DHS partners, including child welfare and vocational rehabilitation as appropriate. Brokering also involves continual evaluation of each service’s usefulness and success. Brokered services include not only case plan activities and local resources, but DHS, Social Security, child support and other benefits as well. Participant confidentiality is critical, so it is important to ask participants to sign an Authorization for Use and Disclosure of Individual Information form (MSC 2099) as soon as possible;
- Case plans are the road map for the participant in their journey toward enhanced self-sufficiency. They are developed using the participant's best thinking on how they can increase self-sufficiency. The results of participant assessment are used to help the participant choose self-sufficiency-enhancing services, and the family coach acts as a broker to access these services. The plan states when, where, how and by whom these activities will be provided. Case plans should be individualized based on participant need and can be added to and adjusted over time;
- Eligibility determination and benefit issuance are one of the primary responsibilities of DHS. These services are integrated with case planning aimed at increasing self-sufficiency. The case plan is the primary agreement between the participant and DHS, and the benefits are one of the temporary supports in that plan;
- Progress evaluation allows DHS to maintain successful case plans and accurate benefit delivery for our participants. This is where the relationship between the participant and DHS staff is developed. Consistency and timely follow up by DHS staff are very important here so that trust, support and accountability are fostered on both sides;
- Narration and computer entry are the means by which our benefits
are provided and activities recorded. They also enable us to collect and evaluate data to continually improve program services. Accuracy and timeliness of narration and computer entry are necessary to help us maintain federal and state funding. Case plans should be entered into TRACS no later than five working days from the date the plan was developed or sooner. Narrations should be clear, comprehensive and void of personal opinion.
All these activities occur during case management, but the order may vary depending on theparticipant's need and local procedures. In each case, we use case management skills such as asking open-ended questions, restating and summarizing, and helping participants develop their own plan of action and be accountable for their own progress. Each of these case management activities are discussed in detail in the following sections, and at the end of the Case Management chapter there are examples of how all these activities can be put into practice in specific examples.
- Retention services
Retention services are meant to enable participants to maintain employment, increase wages and employee benefits, and learn how to access community services for themselves. From the assessment period on, family coaches and JOBS contractors will identify barriers that will hinder participants from retaining or advancing in future employment opportunities and the case plan will include activities to address the barriers. The JOBS program offers activities to improve future employment retention for participants. Many JOBS activities foster new skills for participants that will lead to an ability to obtain, retain and advance in employment, and skills that will promote better employment opportunities with increased wages and self-sufficiency. Participants may also engage in retention services offered by community partners.
Family coaches also offer support to participants who have become employed and are no longer receiving TANF benefits by holding those cases for six months after a TANF closure. During those six months, family coaches check in with participants at least monthly, in order to assist with resources, referrals, and support.
- Targeted Case Management (TCM)
The Self-Sufficiency Program receives federal Medicaid funds through Targeted Case Management (TCM) services provided to TANF participants.
- For a service to be considered TCM and qualify for federal Medicaid funds, a TANF family coach must be providing services to a parent age 14 or older and the services must be:
Activities to identify barriers to self-sufficiency and to identify medical, social, educational and other services needed to remove the barriers;
- - Screening and assessment;
- - Developing case plans;
- - Referrals to service providers; or
- - Monitoring participant compliance with case plans.
Examples of activities that qualify for TCM include the TANF family coach: conducting the Family Assessment (DHS 7823C); substance use disorder (SUD) and mental health screenings (such as the GAIN-SS screening), learning needs screenings (DHS 421); physical health screenings; problem-solving with participants to address barriers; identifying needs and making referrals to appropriate resources; making sure participants are attending the JOBS activities identified on their case plan; and updating case plans.
Examples of activities that do NOT qualify for TCM include: data entry, including entering attendance; processing interim change reports; an HSS3 or case aid making referrals to a service provider; a JOBS contractor doing a screening or helping with case plan development; and an engagement specialist or Disability Analyst providing information about participant barriers.
When a TANF family coach provides a service listed above to a parent age 14 or older, the family coach must take all the following steps so that TCM funding is received:
- Change the case management flag on TRACS to “Yes.”
The case management flag automatically changes to “yes” when a new plan is created and when a worker updates the plan review date. A worker must change the case management flag to “yes” any other time a TCM-qualifying action is taken.
- Narrate which of the TCM-eligible services listed above were provided by a TANF family coach. (For example, narrate “TANF family coach developed case plan with participant” or “TANF family coach screened for SUD/MH.”)
- Random Moment Sample System (RMSS): RMSS impacts the TANF program’s ability to claim and keep federal TCM funding. If a family coach receives an RMSS survey, it is critical the survey be completed accurately according to the work they performed during the RMS survey period. When the family coach is performing TCM during the RMSS survey period, the RMSS survey should be completed as follows:
- Survey section 1 – Activity category: In 1.A Program Activity, select “1.A.2 Self-Sufficiency."
- Survey section 2 – Client Identification: Under 2.A (Case Type Selection), select “2.A.2 Case Specific (activity pertained to a specific case/client)” and fill out the “Case Type/Number (enter ONE relevant case identifier(s)).”
- Survey section 4 – Employee Activity – All Non-Eligibility/Non-Re-Eligibility: Select “4.A.8 Adult/Teen Case Management (Medicaid & TANF Eligible) – TCM Certified staff (Case Managers).” (If you complete RMSS survey section 4, you do not complete section 3.)