CFSP 5 Year Plan - RI Department of Children, Youth & Families

4) Upon successful contact with the member, the Case Manager discusses the Care
Management Program and provides a brief overview of what the member can expect,
including but not limited to the following:
a. A description of the Case Manager relationship
b. Availability of a written care plan upon request
c. Case Manager contact information
d. Neighborhood’s complaint procedures
e. Member’s right to decline participation in the Care Management Programs
and/or disenroll from the programs and/or services offered by
Neighborhood
5) The Care Manager initiates the care planning process with a comprehensive review
of the member’s existing / current medical and the psychosocial concerns / barriers that
contribute to the member’s health status. Case Managers use the automated tools
available within Neighborhood’s case management software to assess and document
the following at the time of initial assessment:
a. Initial assessment of member’s health status including condition-specific
issues and co-morbidities.
b. Clinical history, including disease onset and medications
c. Initial assessment of activities of daily living
d. Initial assessment of mental health status, including cognitive functioning.
e. Initial assessment of life planning activities, including the presence or
absence of an Advance Directive
f. Evaluation of cultural and linguistic needs, preferences or limitations
g. Evaluation of care giver resources / availability of assistance /community
resources
h. Evaluation of in-plan and out-of-plan health benefits available to the
member or if member is already involved with one of these resources
i. School issues/Presence of an IEP or Section 504 plan
j. Housing/transportation
k. General life and health goals
6) The Care Manager requests the member’s verbal acceptance of enrollment into the
Care Management program, and explains to the member his/her rights to decline
participation at any time. Verbal consent or a request to refuse participation is
documented in the program.
7) Care Managers contact applicable external agencies (described above) to better
understand the member’s medical and psychosocial history. Case Managers request a
copy of the Family Care Plan developed by CEDARR Family Services in the case of
members who have an ongoing, established relationship with the agency.
F. Development of the Care Management Care Plan
1) The Case Manager evaluates the information obtained during the initial
assessment and works with the member and his/her practitioner (s), provider
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