Section 2.1: Case Management Coordination

Revised October 2019

2.1.1 CASE MANAGEMENT COORDINATION

Department grantees providing case management services should engage in activities (as described below) to coordinate with other agencies in the grantee's service area that provide case management services to the same types of persons as the grantee has agreed to serve. These activities are intended to avoid duplication of case management services at the local level and ensure that each client has only one lead case manager at any given time.

  1. The case management agency should ensure that every family enrolled in case management continues to utilize primary medical care, regardless of the primary case management agency working with the family.
  2. Case Management Coordination Agreements. Grantees of the Department's Division of Family Services should enter into written agreements with other agencies with the same geographic service area (in whole or in part) and with comparable scope of case management activities regarding coordination of case management services. These agreements must at least specify each grantee's target group for services, referral procedures, procedures to obtain informed consent for services and protection of client's privacy, and procedures to determine the agency most appropriate to provide case management services.
  3. Determination of the Agency or Program most appropriate for the delivery of case management services. Following the assessments of a client's service needs, the case manager, other involved service Agencies, and the client (and the client's parent(s) or legal guardian(s), depending upon the client's ability to consent for services) should determine the one agency or program most appropriate to take a lead role in providing case management services if any of the criteria listed below are met. Only those Agencies for which the client has given written consent may participate in the determination of the most appropriate agency or program to provide case management. The criteria requiring such a determination are:
    1. the participant's most important problem requires expertise for case management that the grantee's staff does not possess;
    2. the participant's most important problem requires expertise for case management that another agency's staff does possess;
    3. the participant's problems are so complex as to require the close collaboration of several agencies for successful case management; and
    4. the participant prefers to obtain case management services from another agency.
  4. Family Case Management Agencies in Chicago / Cook County (Region 1) must comply with the Chicago / Cook County FCM Client Transfer Policy and Procedures.

2.1.2 CLIENT TRANSFER POLICY

Clients may only be enrolled in services at one agency at a time. Based on this, it is essential that all agencies cooperate in adhering to the following client transfer policy to ensure that there is a strong continuity of care for clients, and each client is receiving the most appropriate service based on their individual needs. Every agency is expected to follow the policy as it is written, unless prior approval has been given and documented by the MCH Nurse Consultant.

  1. Clients should be active in the most appropriate program based on their current needs.
  2. If a client is a DCFS Youth in Care and is referred to a HWIL agency by the HWIL Lead Agency and is active in HRIF at another agency, the HWIL agency should notify the HRIF agency, however, may not activate the client until the HRIF agency transfers the case to them. The HWIL agency should notify the Lead Agency as to the status of that child. The HRIF agency will transfer a youth in care to the HWIL agency when one of the following occurs:
    1. The DCFS Youth in Care ages out of the HRIF program
    2. The DCFS Youth in Care no longer has medical issues that require the intensive case management provided by the HRIF program.
    3. The DCFS Youth in Care chooses to no longer participate in the HRIF program.
  3. Prior to activating any client at an agency, it is imperative that a statewide lookup must be completed in Cornerstone. In areas where there may be multiple agencies providing similar services, a lookup must be completed for the mother as well as the infant in cases where an infant has been referred to an agency. If a mother is active at a different agency, the infant should be referred to the original agency where the mother has been receiving services to ensure continuity of care.
  4. Anyone who appears on the HSPR0724 - case finding list should go through the statewide search process in Cornerstone and if that client, or the client's parent / guardian, or sibling is currently receiving services (and active) at another agency, the agency who received notification in the case finding list report, should not reach out to that family, since they will most likely continue to receive services at the agency they are already active with.
  5. Requests for transfer of clients with an Active program status should only be made for one of the following reasons and the client must agree to the transfer prior to it being completed:
    1. the client's most important problem requires expertise for case management that the grantee's staff does not possess;
    2. the client's most important problem requires expertise for case management that another agency's staff does possess;
    3. the client has moved and is now located closer to a different agency; or
    4. the client prefers to obtain case management services from another agency.
    5. In these situations, the agency that the client is presenting to should have a conversation with the client emphasizing the importance of continuity of care. If the client still chooses to change agencies, it should be documented in the Case Notes (CM04) of Cornerstone what the reasoning is for the transfer.

If a transfer of an active client is deemed necessary, based on the reasons given above, the agency receiving the client must communicate directly with the agency who is going to be losing the client to

inform them of the transfer and request that the record be released in Cornerstone. This communication is to be documented in the Case Notes (CM04) of the client record for review at a later date.

Agencies initiating a transfer of a client who is currently active at another agency must complete a Transfer Request Form (ADDENDUM 02 01 02 CLIENT TRANSFER FORM (pdf)) which will be maintained in the client record at both the agency the client transferred from and the agency the client transferred to. These forms must be signed and shared with the program coordinators at both agencies effected by the transfer. These forms may not replace the documentation within the client record in Cornerstone and are not a requirement of the Department.