Care Coordination



SERVICE RECORD--TARGETED CASE MANAGEMENT

|Medicaid Number |Last Name |First Name |Date of Birth |

| | | | |

|WVEIS # |Diagnosis Code |Co. Provider # |County/School |

| | | | |

|Types of Contact |Definition: T1017 = 15 minute unit. Services which assist |Code |Units |

|Face-face |Medicaid eligible recipients to gain access to the needed | | |

|Correspondence |medical, behavioral, health, social, and educational needs, | | |

|Telephone Contact |etc. | | |

| | |T1017 | |

|TARGETED CASE MANAGEMENT NOTES |Date |Type |Time In|Time Out |

|Assessment: The case manager ensures an on-going formal and informal process to collect and interpret| | | | |

|information about student’s strengths, needs, resources, and life goals. This process is used in the | | | | |

|development of an individual service plan. | | | | |

|Note: | | | | |

|Note: | | | | |

|Note: | | | | |

|Note: | | | | |

|IEP/Service Plan: The case manager ensure and facilitates the development of a comprehensive, | | | | |

|individual education service plan. | | | | |

|Note: | | | | |

|Note: | | | | |

|Note: | | | | |

|Note: | | | | |

|Linkage/Referral: Case Mangers ensure linkage to all internal and external services and supports | | | | |

|identified in member’s service plan. | | | | |

|Note: | | | | |

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|Advocacy: Case manager’s advocacy refers to the actions undertaken on behalf of the member in order | | | | |

|to ensure continuity of services, system flexibility, integrated services, proper utilization of | | | | |

|facilities, and resources and accessibility to services. (Includes legal and human rights). | | | | |

|Note: | | | | |

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|Crisis Response Planning: Case manager must ensure that adequate and appropriate crisis response | | | | |

|procedure(s) and accessibility are available to the student and identified in the service plan. | | | | |

|Note: | | | | |

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|IEP Evaluation: The case manager continually evaluates the appropriateness of the student’s IEP | | | | |

|(Individualized Education/Service Plan) and makes appropriate modifications, establish new linkages, | | | | |

|or engage in other dispositions as necessary. | | | | |

|Note: | | | | |

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|Signature and Credentials: | |Date: |

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