Developmental Services - Case Management

Certification Process - Definitions

ADA:  the Americans with Disabilities Act of 1990 (104 Stat 327, Pub. L. 101-336, 42 USC §§12101 et seq.)

Advocate:  a representative of the protection and advocacy agency described at 5 MRSA §§19501-19509. 

Agency:  a firm, partnership, association, corporation, organization or trust certified or seeking certification under these regulations.

Assessment:  the process of identifying the person's needs through in-person contact with the person and, where appropriate, consultation with other providers and with the person's family and guardian.

Case management services:  those services provided by an agency, to identify the medical, social, educational and other needs of the person, identify the services necessary to meet those needs, and facilitate access to those services. Case management consists of plan of care development, coordination/advocacy, monitoring, and evaluation.

Certification:  the process whereby an applicant agency is determined to be qualified to provide case management services to adults with intellectual disabilities under the provisions of the MaineCare Manual (10-144 CMR 101), Section 13, Targeted Case Management.

Civil Rights Act:  Civil Rights Act of 1964, Pub. L. 88-352, as amended.

Commissioner:  the Commissioner of the Department of Health and Human Services.

Coordination/Advocacy:  the process of facilitating the person's access to the services and resources identified in the care plan. The case manager may advocate on behalf of the person for appropriate community resources and coordinate the multiple providers of social and health services defined in the care plan. As part of the coordination function, the case manager will avoid the duplication of services.

Cultural competence:  the ability to understand, respect and effectively work with persons/groups with various cultural backgrounds including age and gender.   

Department:  the Department of Health and Human Services.

EEO:  The Equal Employment Opportunity Act of 1972 (Pub. L. 92-261), as amended.

Eligibility:  the process of determining if an individual is eligible for developmental disability services according to 34-B MRSA Ch. 5.

Evaluation: the process of determining whether the care plan is appropriate, whether a new plan is necessary, or whether services should be terminated. Evaluation is accomplished through periodic in-person reassessment of the person, consultation with other providers, and, if appropriate, consultation with the person's family and guardian.

Fee schedule:  a document listing the charges for all services available from the service provider.

Governing Body:  an individual or association of persons with ultimate managerial control and legal responsibility for the operation of a program or service and for defining the program or service authority and structure.  Normally, the Governing Body discharges its responsibilities by employing a chief administrative officer and formulating policies for the agency’s authority and structure.

Guardian:   person(s) or agency with ongoing legal responsibility for ensuring  the care of an individual, appointed pursuant to 18-A MRSA, Article 5, Part 3. 

HIPAA:  Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191).

Informed consent:  consent obtained in writing from an individual or the individual’s legally authorized representative for a specific treatment, intervention or service.  Elements of a valid informed consent include information to assist the individual to make the consent, including the diagnosis, the nature and purpose of the procedure(s) or service(s) for which consent is sought, all material risks and consequences of the procedure(s) or service(s), an assessment of the likelihood that the procedure(s) or service(s) will accomplish the desired objective(s), any reasonably feasible alternatives for treatment, with the same supporting information as is required regarding the proposed procedure(s) or service(s), and the prognosis if no treatment is provided.

Intake:  a process whereby a case manager or qualified intake worker meets with the individual, the individual’s family and the individual’s guardian if one has been appointed, for the purpose of providing information regarding services, collecting evaluations and diagnoses to determine service eligibility, and conducting an assessment for planning purposes. 

MRSA:  Maine Revised Statutes Annotated.

Maine Human Rights Act (MHRA):  5 MRSA §4551, et seq.

Mental retardation: as defined at 34-B MRSA § 5001, a condition of significantly sub average intellectual functioning resulting in or associated with concurrent impairments in adaptive behavior and manifested during the developmental period.

Monitoring:  the process of ensuring that the person's care plan is implemented and assessing progress towards meeting the objectives outlined in the care plan. It includes contact with the person as needed to monitor the care plan objectives and, if appropriate, periodic contact with the person's family and guardian.

Person:  Person receiving services.

Plan of Care Development:  the process of determining, with the person, and unless inappropriate, the person's family and guardian, and other providers, what services and resources are necessary to meet the identified needs and how they might be most appropriately delivered. The plan of care is designed to maintain current service delivery and to resolve gaps in services so that comprehensive care is attained.  The plan of care development must be consistent with requirements of Person Centered Planning.
 
Policy:  a statement of the principles that guide and govern the activities, procedures, and operations of a program or the provision of services.

Procedure:  a series of activities designed to implement the goals or policies of a program.

Quality management:  processes designed to improve the quality of care of services within an organization.  Quality management includes quality assurances and quality improvement activities.

Rehabilitation Act:   Rehabilitation Act of 1973 (87 Stat. 355, Pub. L. 93-112, 42 USC §§701 et seq.)

Referral: (1) a request for a particular service at an agency or agencies known to provide that service for a specific individual by the individual, a family member, a guardian or by another entity (such as a health care provider or case management agency) with the permission of the individual or guardian if one has been appointed;  (2) a transfer of information about an individual to another agency for purposes of seeking services from that agency on the individual’s behalf.  Documentation of the referral process and informed consent are required elements of a referral.