COMPONENTS: Service Activities shall include: Assess Participant’s Needs: Use the Screen for NJ Community Services (SCS) to assess the needs of the participant, including the ability of the participant to obtain, arrange, and manage his or her own care. The Care Manager may utilize the SCS results from another staff person in the AAA, or by an agency which is contracted specifically for this purpose. Screeners shall obtain consent for release of information. The details of the verbal consent shall be documented in the participant’s record located in the state designated database. The DoAS LTSS “Authorization for Release of Information” shall be mailed or given to the participant for their signature. Returned forms may be scanned and uploaded into the consumer record in the state database. Assessment would include field visits or home visits, based on consumer needs. Develop a Care Plan : Develop an individualized plan of care (POC) based on assessment of the participant's needs and eligibility for services and in collaboration with the participant. The POC shall include goals, back up plans, and reassessment date. Starting with the date of referral (the date a consumer is formally assigned to a Care Manger), the Care Manager shall: Contact the ADRC consumer within three business days. Complete an in-home visit within seven business days with the participant. Complete the participant’s POC within 30 calendar days and obtain signatures from the consumers. Based on the assessed needs, unmet needs, and unique requirements for the provision of the service, the POC shall identify and authorize the type, amount, frequency, duration and provider (including informal) of each service. Implement Care Plan: Obtain formal and informal services according to an individualized care plan. This includes advocacy on behalf of the participant: to interpret, apply for, and secure benefits and services.
