Case Management and Supports Coordination

Gratiot Integrated Health Network

Program Description

Case Management/Supports Coordination/ SUD Case Management

Service Codes: T1016, T1017, H0006

Program Philosophy: Gratiot Integrated Health Network provides services to build resilience, and to support the recovery or well-being of individuals and the integration of individuals served into the community. Through service provision, symptoms or needs will be reduced and individuals will experience an improvement in level of functioning in their environment. The program strives to continually improve service provision in order that individuals served experience an enhanced quality of life.

Program Goals:  The goal of Case Management/Supports Coordination services is to provide goal-oriented and individualized services that focus on increasing independence and self-sufficiency for the persons served through assessment, planning, linking, advocacy, coordination and monitoring activities.  An increase in independence and community inclusion opportunities for persons served is the result of successful case management/supports coordination.

Services/Scope of Services: Based on the needs and choices of the person served and with their participation in treatment planning and service provision case management/supports coordination includes: coordination of services, follow-up, monitoring, referral, outreach, facilitation of activities which promote community inclusion, assistance with community linkage and enhanced social support networks, coordination of assistance with crisis intervention and stabilization services, assistance with accessing transportation, exploring employment or other meaningful activities, and advocacy.  A person centered treatment approach is used to help identify the individual’s strengths, dreams, goals, and desires.

Populations served include individuals with SUD/co-occurring disorders, intellectual developmental disabilities, adults with serious mental illness, and children with severe emotional disturbance, who have multiple service needs, have a high level of vulnerability, require access to a continuum of mental health services, and/or are unable to independently access and sustain involvement with needed services.  Services are provided in the location that best meets the need of the service being provided (i.e., at the agency, individual’s home, community) based on the choice of the person served.

Services are provided Monday through Friday from 8:00 a.m. to 5:00 p.m. and by appointment.  Crisis Intervention, Access, and Customer Service activities are provided 24 hours a day, 7 days a week, allowing those who are accessing services to schedule an appointment, to allow for a message to be left for clinicians or Customer Service Staff, or in an emergency situation to access a crisis worker.

The frequency of services received by persons served is based on individual medical necessity and is outlined in the individual plan of service.

Services are initiated at the request of the individual, parent or legal guardian.  Information from referral sources will be accepted after proper consent for release of information is obtained. Services will not be denied based on an individual’s inability to pay for services.

Admission/Re-Admission Criteria:  The Access Coordinator, in conjunction with the program supervisor, is responsible for prioritizing the admission/readmission of eligible individuals based on the severity of needs.  Amount, scope, and duration of service provision is determined based upon evaluation of medical necessity and will be specified in the individual plan of service.  Medical necessity is determined based upon a thorough psychosocial assessment, standardized functional assessment tools (i.e.SIS, CAFAS, LOCUS, etc.), and the clinical judgment of trained professionals.  Based upon the aforementioned evaluation, individuals will be assigned a level of care benefit plan, specifying a minimum and maximum range of service units.  Exceptions to level of care benefit plans will be reviewed by the Utilization Management department.

It is the policy of Gratiot Integrated Health Network to provide services to all eligible consumers in a manner that is sensitive to the cultural and socio-economic needs of the individual in a nondiscriminatory and/or non-threatening manner.  Services are provided to eligible individuals without regard to race, religion, color, national origin, age, sex, marital status, sexual preference, handicap, juvenile justice status or any other protected status as required by law.  The agency endeavors to accommodate individuals with special needs, or refers to providers equipped to meet their needs.

Eligibility criteria for Case Management/Supports Coordination services include individuals who have/are:

  • a primary DSM-V diagnosis of Serious Emotional Disturbance, Serious Mental Illness, SUD/Co-occurring Disorder, or Intellectual Developmental Disability
  • primary residence in Gratiot County
  • Medical Necessity (clinically appropriate; necessary to meet needs; consistent with diagnosis, symptomatology and functional impairments; in the least restrictive environment; and consistent with clinical standards of care)
  • the ability to benefit from generally accepted Case Management/Supports Coordination practices
  • a willingness to participate in treatment planning
  • consent to treatment

For a child age 14 or older who is seeking services without parental consent, GIHN will be prepared to offer limited services in accordance with PA 186 with program supervisor approval.

When individuals are found to be ineligible for services, they are given the reason(s) and are directed to alternative or more appropriate services.  In addition, when applicable, the family/support system and/or the referral source are informed as to the reason for ineligibility. Assistance in contacting alternative services is available upon request.

Transition/Discharge Criteria:  An individual may be transitioned or discharged from Case Management/Supports Coordination when one or more of the following occur:

  • Successful completion of the goals set forth in the Individual Plan of Service
  • Individual request
  • Lack of individual participation in treatment
  • Individual requires a different level or type of service based on medical necessity
  • Individual no longer meets established eligibility criteria

When an individual is discharged or removed from the program for aggressive and/or assaultive behavior, follow-up will occur within 72 hours to ensure linkage to appropriate care.

Regardless of discharge status, any individual may reapply for services by contacting GIHN.