IV. E. Case Management Policy

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IV. E. Case Management Policy

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Children who have experienced trauma, abuse, neglect, and maltreatment may present with social, emotional and behavioral challenges that can range from acute to long-term.  Due to the significant and known risks associated with early onset of emotional and behavioral difficulties, systematic, timely, effective and reliable identification and intervention is essential.  Conversely, children who are not in need of clinical interventions should not be subjected to unnecessary or contraindicated treatment due to risk of negative outcomes.


Case management involves working with families to assess needs and develop plans of support, thereby assisting families in meeting the developmental and therapeutic needs of their children.  Family members and natural supports must be engaged in both the assessment and planning process in order for protection and permanency efforts to be effective.  


This policy supports our Practice Model in that it affirms strengths of the child and family as well as needs.  It focuses on assessing the signs of behavioral, developmental and/or mental health needs of the child in order to capitalize upon strengths, while providing the family with the full level of support they need in order to reduce risk and danger and maximize well being of the child.  This policy promotes family engagement and a team approach to planning and intervention.





The Department of Health & Human Services (DHHS) is responsible for assuring that children in its care and custody receive needed health care services.  This includes preventive care, diagnosis, and treatment of identified needs.  To facilitate this, all children in the care and custody of DHHS will participate in behavioral health screening and case management, regardless of MaineCare status.


The provision of case management is defined as services that assist eligible individuals in gaining access to needed medical, social, educational, and other services.  "Eligible individuals" refers to vulnerable populations, such as children and families in the child welfare system or children with behavioral health needs.


Case management includes:

 a. Assessing the child's needs;  

 b. Coordinating the delivery of appropriate services as defined in the assessment;  

 c. Assisting the child and family in accessing appropriate services;  

 d. Monitoring the child and family's progress by making referrals, tracking appointments, following up on services rendered, and periodically reassessing the child and family’s needs;  

 e. Advocating on behalf of the child and family;  

 f. Consulting with service providers or collateral contacts to determine the status or progress of the child and family's plan;

 g. Arranging for crisis assistance, such as coordinating needed emergency services; and

 h. Continually assessing for safety, risk & danger.


This policy sets forth the expectation that all children receiving child welfare services will receive behavioral health case management as a function of their DHHS caseworker.  Targeted Case Management services for a child’s behavioral health needs will not be accessed through a DHHS contracted provider while actively receiving Child Welfare case management services.





Title 22 MRSA § 4003: "… Recognizing that the health and safety of children must be of paramount concern … "


Title 22 MRSA § 4004 Subsection 2.e.1-2: " If … the department … does open a case to provide services to the family to alleviate child abuse and neglect in the home, assign a caseworker, who shall: (1) Provide information about rehabilitation and other services that may be able to assist the family; and (2) Develop with the family a written child and family plan.  The child and family plan must identify the problems in the family and the services needed to address those problem; …"


Title 34-B MRSA MRSA §15002 Subsections 1-3:  "The Children’s Mental Health Program is established to identify children with mental health needs and to improve the provision of mental health care to children and supportive services to their families … The program is child and family-centered, focusing on the strengths and needs of the child and the child’s family and providing care to meet those needs."

 §15002.2.C: "The program promotes prevention, early identification and intervention for children in need of care and at risk of developing emotional problems."

 §15002.3.A: "Using the resources of the departments, the program must provide the child and family with a central location for obtaining information, applying and being assessed for care and supportive services, maintaining contact with case managers and department staff and, to the extent possible, obtaining care and supportive services."

 §15002.3.C: "The system of providing care must be functionally integrated, network-based system with the department as the single point of accountability."



Title 34-B MRSA §5003:  "To facilitate the development of a system that meets the needs of persons with mental retardation or autism, the commissioner shall:

 §5003.2.A: "Provide a mechanism for the identification, evaluation, treatment and reassessment of and the provision of services …"

 §5003.2.B: "Identify the needs and desires of persons with mental retardation or autism through appropriate personal planning …"

 §5003.2.E: "Eliminate the department’s own duplicative and unnecessary administrative procedures and practices in the system of care for persons with mental retardation or autism, encourage other departments to do the same and clearly define areas of responsibility in order to use present resources economically."





Assessment: The process of identifying a child and family’s strengths, problems and service needs for the purpose of developing the child and/or family’s plan.


Individual Support Plan (ISP): A comprehensive plan of care for the child and family that is based on an assessment of strengths and needs across the life domain areas, from which specific goals and measurable objectives are developed.  The identified goals and objectives should be appropriate to the child and family’s cultural needs.


Individual Treatment Plan (ITP): The plan of care for a specific service developed by the treatment team in consultation with the family.  The ITP uses a strengths-based and culturally competent approach to assess the treatment needs of a child and, when appropriate, her/her family circumstances.  The ITP must be appropriate to the developmental level of the child and shall address all the domains of a child’s life.  When there is an ITP for identified service(s), it should be referenced in the ISP.


The ITP must specify the following:

 a) The service components to be provided;

 b) The names and titles of those who will be accountable for provision of the service;

 c) The frequency and duration of each service component;

 d) The expected duration of treatment; and

 e) The expected short and long-range treatment and/or rehabilitative goals or outcomes of the services.


Medically Necessary Services: Services provided for the purpose of preventing, diagnosing or treating an illness, injury, condition or disease in a manner that is:

 •  Consistent with generally accepted standards of medical practice;

 •  Clinically appropriate in terms of type, frequency, extent, site, and duration;

 •  Demonstrated through scientific evidence to be effective in improving health outcomes or is generally accepted as representative of "best practice" in the medical profession;

 •  Not primarily for the convenience of the child, their family, physician, or health care practitioner.


Pediatric Symptom Checklist: A validated psychosocial screening tool for children 4-16 years of age designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible  (Jellinek, Murphy, Robinson, et al., 1988).


Targeted Case Management Services: Utilizes a child-centered and family-focused process to develop and coordinate individual support plans and monitor services to be provided to a child and his/her family or guardian.  This process is undertaken with participation and consultation from the family, a multidisciplinary team of professionals, and other support people chosen by the family, child and team.





A.   Screening


A comprehensive behavioral health psychosocial screening must be administered to all children receiving child welfare services.


This screening will be:

 •  Completed within 30 days of opening the case for services;

 •  Obtained through face-to-face contact with the child and at least one parent or caregiver; and

 •  Updated annually (or sooner should an identified need arise) for those children who do not carry a documented behavioral health diagnosis.


Systematic detection of child difficulties enables the initiation of appropriate interventions as early as possible.  To appropriately identify and address the emotional and behavioral health needs of children who receive child welfare services, a universal and validated screening is required.  It is the determination of DHHS to use the following screening tools and resources:


Children up to age 4:  Caseworkers will refer all children in this age range to Child Development Services (CDS) for screening and evaluation.  For more information, please refer to Policy IV.D-5 Mandatory Referrals to Child Development Services.


Children ages 4 through 16:  The Pediatric Symptom Checklist (PSC) will be used to screen children in this age range for clinically significant behavioral, cognitive, and emotional challenges.  The PSC has been validated for use with children and families in samples representative of child welfare populations.  Caseworkers are responsible for administering and scoring the screening tool.



PSC & Y-PSC: Instructions for Use


The PSC is a thirty-five (35)-item questionnaire recommended for use with children ages 4-16 years.  Parents or other caregivers answer the questions independently or through discussion with the caseworker.  Children ages 11-16 years are encouraged to complete a companion youth version, the Youth-Pediatric Symptom Checklist (Y-PSC).


 1. The PSC is used for children ages 4 through 16.  

 2. The caseworker administers the PSC within 30 days for children where there is a substantiated or indicated finding and the family is receiving child welfare services.  Children and families already receiving child welfare case            management services as of the effective date of this policy should be administered the PSC only if an emergent behavioral, cognitive, and/or developmental need is identified by the family, child, and/or family team.  Children                  who have an evaluation from a qualified, licensed professional dated within the last year do not require a PSC or Y-PSC.

 3. The caseworker informs the parent/caregiver and child of the purpose of the PSC screening and how the findings will be used in service planning.

 4. Respondents may complete the PSC independently or the caseworker may engage the parent/caregiver/youth in the process by discussing the questions together.

 5. Children and youth ages 11-16 should be encouraged by the caseworker to complete the Y-PSC.

 6. Scoring: The PSC consists of 35 questions/items that are rated as ‘Never" (Score=0), "Sometimes" (Score=1), or "Often" (Score=2).  Items that are left blank are simply ignored (i.e., score equals zero).  If four or more items            are left blank, the questionnaire is considered invalid.  The total score is calculated by adding the cumulative scores for all the questions/items.  A Positive Score or higher suggests the need for further evaluation by a                    qualified licensed health (e.g. M.D., APRN) or mental health (e.g. Ph.D., LCSW) professional.






Positive Score


4 – 5


24 or higher


6 – 16


28 or higher


Y-PSC (ages 11-16)


30 or higher




 7. Children with positive scores as outlined above may be referred to a licensed health or mental health clinician for further evaluation.  Both false positives and false negatives can occur, and only an experienced professional                    should interpret a positive PSC or Y-PSC score as anything other than a suggestion that further evaluation may be helpful.  Prior to making a referral, the caseworker reviews the case with the designated District                            OCFS/Children’s Behavioral Health Services consultant.  The consultation should be used to review the child’s behavioral health needs and identify appropriate resources for evaluation and treatment.

 8. The caseworker discusses the score and its indications with the family/caregiver, child, and family team.

 9. In general, children whose scores fall below the Positive Score should not be referred for further assessment or treatment.  However, if the caseworker and supervisor believe that a referral is indicated due to the child’s unique            needs despite the PSC score, consultation with Children’s Behavioral Health Services, along with discussion with the family and the team should precede any referrals.  


It is understandable if families experiencing a substantiation of abuse and/or neglect are reluctant to answer questions about their children in a way that they believe may reflect negatively on them in the eyes of DHHS and/or the court system.  As such, it is important that the PSC is used in a manner that is sensitive to parental concerns and considers possible response biases and other factors unique to this population.  It is also vital that this tool be used with respect to the family and youth’s cultural and linguistic needs.  The PSC has been translated into 15 languages and a pictorial version.  Translations and pictorial versions are available online at www.massgeneral.org/allpsych/psc/psc_forms.htm



B.        Service Planning

Children identified in need of further assessment and treatment should be referred to the most appropriate services based on their specific and unique needs.  The caseworker will work with the family, child and the family team to identify the specific needs and develop a plan to meet these needs.


Documentation Guidelines:


1.The statement of needs and the plan to meet the identified needs should be clearly described and tracked in MACWIS.

2.Need statements should be as specific, child-centered, culturally appropriate, and strengths-based as possible.  

3.Each need statement should be followed by an outcome statement, which provides a clear and measurable picture of what will happen when the child/family successfully meets the need.  

4.A specific plan to meet the need with a target date of completion should be clearly and concisely described.


The service plan should be developed within 30 days from the positive PSC score and updated every six months or as the needs change.  Service planning should take place in context of a Family Team Meeting with input and participation from team members.  The plan should be monitored monthly during contact with the child and family/caregiver, and progress tracked in the narrative log.


C.        Referral

For children in DHHS custody, the caseworker has primary responsibility for deciding when and from what provider evaluation and treatment will be provided.  This decision is made following consultation with the designated OCFS/Children’s Behavioral Health Services consultant, the family and/or primary caregiver, the child’s physician, and the family team.  For children not in custody but receiving services, the caseworker and the family should come to the decision together and after consultation with others as outlined above.


The caseworker is responsible for scheduling and arranging services and transportation as necessary.  The family should take part in the treatment whenever clinically indicated.


D.        Transition Planning


Efficient and sensitive transition of case management services is essential.  The Family Team Meeting planning process will be the method for transitioning children to single case management services.  The following categories of children require transition planning and methods to facilitate the transition:


       1. Children currently receiving Child Welfare case management services and Targeted Case Management services (MaineCare Section 13.12) through a contracted provider agency.

 2. Children entering the Child Welfare system who are receiving Targeted Case Management services from a contracted provider agency.  

 3. Children entering the Child Welfare system without a Targeted Case Manager.  These children will be screened for behavioral health needs as outlined in Section A with service planning as outlined in Section B.


For children in categories 1 and 2, behavioral health case management services will be transferred from the contracted agency to the DHHS Child Welfare caseworker.  Prior to the transition of services, the caseworker will meet with the contracted case manager and family/caregiver to review the Individual Support Plan (ISP) and devise a plan to transition ISP goals to the DHHS caseworker to be documented in the Family and/ or Child Case Plan.  A Family Team Meeting will be convened within the timeframes in policy or as soon as is practicable to effect the transition to the DHHS caseworker.


Cases in active status as of the effective date of this policy, where the plan is for a child and family to be discharged from Child Welfare case management within the next three (3) months, the caseworker and the family team may decide it is in the child’s best interest to remain with the present Targeted Case Manager to ensure continuity of care at case closure.  Cases receiving both case management services (child welfare and Targeted Case Management) require review and approval by the casework supervisor.


Children with special circumstances (such as a chronic or severe medical condition) or who are members of a special population (such as Deaf/Hard of Hearing, refugee status, mental retardation, or a diagnosis of Pervasive Developmental Disorder) may benefit from the services of both a Targeted Case Manager and the DHHS caseworker.  The decision to provide dual case management should be based on the child’s unique needs and made in the context of the Family Team Meeting process.  If the Family Team Meeting does not reach consensus as to dual versus single case management, consultation should be sought from CBHS and the child’s clinician/therapist (if there he/she has a clinician) as to the child’s clinical needs.  If consensus cannot be reached from the consultation process, the final decision rests with the parent/legal guardian.  Families with open Child Protective Services cases who retain custody of their children have the right to choose the case management provider for their child.  Children receiving Treatment or Therapeutic Foster Care services will continue to receive case management services through the contracted provider and are not impacted by this policy.


E.        Case Closure


The case closure process should be discussed regularly with the family and the team from the onset of service.  Caseworkers monitor the child’s mental, behavioral and developmental health needs throughout the progression of a case via regular case contacts, family team meetings, treatment team meetings, case plan reviews, and collateral contacts.  In preparation for closure, caseworkers also coach the family/caregiver in meeting the child’s behavioral health needs and arranging for services.  Behavioral health needs that are met are documented in MACWIS.  Upon the family’s exit from child welfare services, the narrative log and Case Plan should include a summary of the child’s course of service/treatment, a description of any ongoing needs at discharge, and the plan to meet these needs in the community.  The family’s role in meeting these needs should be outlined as well.


The Family Team Meeting process will be used to plan for a child and family’s continuing need for services.  Children who will continue to need behavioral health case management following case closure will be connected to an appropriate Targeted Case Management agency by the caseworker within 30 days to the projected closure date to ensure continuity of care.


For youth requiring transition to adult services, please refer to the Memorandum of Understanding: Protocol for the Coordination of Transition of Children under OCFS Care to the Adult Service Programs (October 2002).