case manager taking notes while talking with Maria

Additional considerations concerning termination of case management services:

In planning with the client the closure of AMH-TCM services, the case manager and client should consider the following questions:

  • Are the client’s chosen goals and significant functional limitations being addressed by other services/resources/supports; and are those services/resources/supports generally stable?
  • Does the client (and/or the client’s support system) have adequate skills (assessment and service planning, informal support and network building, use of community resources, linking and accessing services, monitoring of service delivery, problem resolution) in most areas for the client to function as his/her own case manager?
  • Is the client free of major unstable situations (i.e., present or recent hospitalization/residential treatment/psychiatric crisis, unstable housing, unstable major symptoms, unstable health/financial benefits, active substance abuse, significant vulnerability, complex physical health problems that are not well managed, major changes anticipated in near term (example: starting college) in the client’s life?  Are prevent/intervention steps in place if there are unstable situations?
  • Does an alternative service exist that the client prefers that can address the needs of the client for a case manager?
  • Has the role of the case manager moved from focus on referral and linkage to primarily monitoring of the existing ICSP?  Has the monitoring role existed for 6 months?

If a client is moving, the case manager should assist the client in accessing a new MH-TCM provider and other needed services and resources in the client’s new community.  The case manager should, with releases, share current FA’s, ICSP’s, and a discharge plan with the new MH-TCM agency.