Mental Health-Targeted Case Management

Referral, Monitoring and Documentation

Documentation

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Client assessment, functional assessment, screenings and level of care assessments

Assessments, functional assessments, screenings and level of care assessments used to describe the client and his/her preferences, status, functioning, and resources should be maintained in the client’s file.

The functional assessment documentation should include:

• Individualized written narrative covering at least the 11 domains noted in the statutory definition of functional assessment (Minnesota Statute 245.462, Subd. 11a).  Numerical rankings and checkboxes are not sufficient.
• A written functional assessment needs to be completed within 30 days of beginning adult MH-TCM services, and a new functional assessment completed at least every 180 days thereafter.  More often, if the client requests.  The functional assessment needs to be written by a mental health professional, or signed by the clinical supervisor of the case manager.
• The functional assessment should note the client’s name, and date of completion of the functional assessment.
• Strong assessments must incorporate the client’s perspective, preferences, strengths, resources, and needs.  Functional assessments are not processes that are done to clients, but processes that are done with clients. 
• Consideration of the client’s culture and incorporation of cultural considerations into the ICSP and service provision.
• client progress toward ICSP goals should be incorporated into the reassessment process and updating of the ICSP in the MH-TCM process.

In each of the domains, the client’s status and functioning should be described.  In each domain, if the symptoms of the client’s mental illness are interfering with/impacting the functioning of the client, this should be noted and described.  Status describes what is; function describes what the status looks like – the how – the behavior.

Comparing Status and Function Example (brief example)

Domain	Status	Functional Description	Functional Limitations Link to MI or other condition (if any)
Vocational Functioning	Does not have a job	Difficulty following instructions, difficulty in persisting in completing tasks, difficulty with punctuality	(discussed next)
Medical Health	Has diabetes	Does not recognize symptoms of diabetes, self-care limited in managing food intake, does not take medications are prescribed, does not consistently maintain follow up appointment with doctor	(discussed next)