UTAH DEPARTMENT OF HUMAN SERVICESDIVISION OF SUBSTANCE ABUSE ANDMENTAL HEALTHTRAINING MANUAL FORCHILDREN & YOUTH CASEMANAGEMENT SERVICESFourth Edition(June 2016)
ACKNOWLEDGEMENTSThese Guidelines have been developed by: The Utah Preferred Practice Consensus Panel underthe auspices of the Utah Division of Substance Abuse and Mental Health and the UtahBehavioral Healthcare CommitteeInitial Adoption December 1998Revised December 2003Revised May 2004Revised June 2016Utah DSAMH Children and Youth Case Management Field Guidei
Table of ContentsIntroduction .1Chapter I: Overview of Utah’s System of Care Values and Principles .3Utah’s System of Care Values and Principles .3Behavioral Health Services for Children .3Qualified Case Management Providers .3Targeted Case Management Curriculum .5Chapter II: Delivery of Services .6Ethical Guidelines .6NACM Ethical Guidelines .6Chapter III: The Care Coordinator Tool Box .8Overview .8Individualized Service Planning .8Needs Assessment .9Rationale for Family Strengths Conversation .9What is the Strengths Assessment?.10Use of Life Domains .10Conducting a Strengths Conversation .11Prioritizing Needs .12Service Plan Development and Implementation .12Goal Setting .13Monitoring the Service Plan .13Indicators of Effective Service Planning .14Criteria for Successful Case Management Discharge .14Chapter VI: Family and Professional Partnership .16Families as Effective Participants .16What Families Bring to the Relationship .16Strategies for involving Families .17Chapter V: Education and Case Management .18Case Management Providers, Students and Schools .18Special Education: IDEA, Section 504, Americans with Disabilities Act .18Case Management Providers Can Help Families through Educational Process .19Chapter VII: Crisis and Safety Planning .20Predict, Prevent and Plan .20Effective Crisis Plans .20Safety Plans for Children .20Developing a Safety Plan .21Problem Behaviors That May Precipitate a Crisis .21Illegal Behaviors .21Substance Abuse .21Threatening, Violent or Homicidal Behavior .22Suicidal Thoughts and Behaviors .22Crisis and Safety Planning Tools .22Columbia Suicide Severity Rating Scale .22Stanley Brown Safety Plan .22Utah DSAMH Children and Youth Case Management Field Guideii
Chapter VIII: Policy, Procedure and Supervision.24Appendix .25Utah DSAMH Children and Youth Case Management Field Guidei
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I. INTRODUCTIONWhy a Case Management Field Guide?This guidebook was written to help prepare you for one of the most important jobs in communitybehavioral health today. It will be a study guide as you prepare to take a formal exam required bythe Division of Substance Abuse and Mental Health. It will be a resource manual for you at thebeginning of your training and a reference you may use throughout your career.This field guide is a companion in your work. Like any new textbook or course of study, thisfield guide should be considered just a beginning.Case management providers should be familiar with the following manuals: Utah Medicaid Provider Manual: Rehabilitative Mental Health and Substance UseDisorder Services Utah Medicaid Provider Manual: Targeted Case Management for Individuals withSerious Mental IllnessThese manuals will help you know how case management services differ from otherbehavioral health services such as personal services, peer support services, skillsdevelopment services, and psychosocial rehabilitative services.A Brief Historical PerspectiveOn average, between 14 and 20 percent of young people experience a Mental, Emotional, orBehavioral (MEB) Disorder – such as depression, a conduct disorder, and/or a substance usedisorder – at any given point in time. It is estimated that over half of all lifetime cases ofdiagnosable mental illness begin by age 14 and three-fourths by age 24. Early onset of MEBdisorders is predictive of: Lower school achievement Alcohol Use/Abuse Chronic Obstructive Pulmonary Disease Depression Fetal Death Poor Health-Related Quality of Life Illicit Drug Use Ischemic Heart Disease Liver Disease Risk for Intimate Partner Violence Multiple Sexual Partners Sexually Transmitted Diseases (STDs) Smoking Obesity Suicide Attempts Unintended PregnanciesA Serious Emotional Disturbance (SED) touches every part of a child’s life. Therefore, childrenwith SED and their families need many kinds of services from a variety of sources such asUtah DSAMH Children and Youth Case Management Field Guide1
schools, Local Mental Health Authorities and Local Substance Abuse Authorities, and socialservice organizations.A case management service provider facilitates the individualized service plan that is being usedto identify and coordinate services for a child or adolescent with SED and the family, as it relatesto the child or adolescent. This person identifies the role that each service provider fills andcoordinates all services. The goal is to make sure the plan builds on the child’s strength andmeets the unique needs of both child and family as it relates to the child. As the child’s needschange, his or her case management service provider notes these changes and adjusts the mix ofservices, if necessary.What is Case Management?In Utah, the Local Mental Health Authorities (LMHAs) and Local Substance Abuse Authorities(LSAAs), under contract with the State Division of Substance Abuse and Mental Health(DSAMH), are responsible for case management in their local areas as defined by Utah CodeAnnotated 17-43-301(4)(b) and State Rule R523-7-4. Case Manager Certification. Casemanagement services help consumers develop goals to coordinate, advocate, link and monitorservices, and facilitate the achievement of goals. When working with children and youth,consumers refers to both children and youth and their families. Providers of case managementservices offer the energy and organization to see that these plans result in real benefits forconsumers. Case management may be provided by one person or a team of providers, and is aservice that assists consumers in gaining access to needed health (including behavioral health),social, educational, and other services. The overall goal of case management is not only to helpconsumers to access needed services, but to ensure services are coordinated among all agenciesand providers. Case management may be done in the consumer’s home, place of employment,shelter, on the streets, residential, and in various other settings. The frequency of contact may bemore to less intensive depending on the individual’s needs.Like other citizens, consumers of behavioral health services have the ability to live asproductively as possible and to receive the treatment they need with minimum interference andmaximum support. A well-conceived recovery/treatment plan and case management needsassessment and/or case management service plan will match an individual consumer’s strengthsand needs to specific community resources. For many Utahans who access behavioral healthservices, case management can make the difference between isolation and productive communityconnections.Utah DSAMH Children and Youth Case Management Field Guide2
Chapter I: System of Care Values and PrinciplesOverview of Utah’s System of Care Values and Principles for Children withSerious Emotional Disorders and Their FamiliesUtah System of Care Values and PrinciplesThe Utah System of Care Values and Principles is grounded on core principles and values. Themodel is multi-dimensional and interdisciplinary with families as partners in a child-focused,family driven, community based, and culturally competent manner of service delivery targeted tokeep children at home, in schoo1, and in the community.Behavioral Health Services for Children in UtahThe public behavioral health system in Utah has a primary responsibility for providingbehavioral health services to children with Serious Emotional Disturbances (SED) and theirfamilies and for meeting the behavioral health needs of the children in our State.Qualified Targeted Case Management ProviderTargeted case management for the chronically mentally ill may be provided by, or through, a behavioralhealth center (or other entity) under contract with or directly operated by a LMHA/LSAA.Qualified providers are:A. Qualified providers of targeted case management services to recipients in this target group areemployed by or under contract with one of the following:1. a local mental health and/or substance abuse authority;2. a local authority’s designated mental health and substance use disorder services provider;3. the Department of Human Services; or4. a program providing Medicaid-covered services, including targeted case management services forindividuals with serious mental illness, under the authority of 1915(a) of the Social Security Act(i.e, HOME). Providers authorized under Section 1915(a) of the Social Security Act providetargeted case management services only to Medicaid recipients enrolled in the 1915(a) program.B. Primary providers of targeted case management services are:1. licensed social service worker or individual working toward licensure as a social service workerin accordance with state law under supervision of a licensed mental health therapist;2. licensed advanced substance use disorder counselor (ASUDC) or substance use disordercounselor (SUDC) under the general supervision of a licensed mental health therapist identifiedin C.1 of the Utah Medicaid Provider Manual: Targeted Case Management ;3. certified advanced substance use disorder counselor (CASUDC) or a certified advanced substanceuse disorder counselor intern (CASUDC-I) under direct supervision of a licensed mental healththerapist identified in C.1 of the Utah Medicaid Provider Manual: Targeted Case Management, ora licensed ASUDC qualified to provide supervision;4. certified substance use disorder counselor (CSUDC) or a certified substance use disordercounselor intern (CSUDC-I) under direct supervision of a licensed mental health therapistidentified in C.1 of the Utah Medicaid Provider Manual: Targeted Case Management, or alicensed ASUDC or SUDC qualified to provide supervision;5. licensed registered nurse;6. licensed practical nurse under the supervision of a licensed registered nurse or a licensed mentalhealth therapist identified in C. 1 of the Utah Medicaid Provider Manual: Targeted CaseManagement;Utah DSAMH Children and Youth Case Management Field Guide3
7. individual who is not licensed who is at least 18 years old and under the supervision of a anindividual identified in C.1., C.2., or C.3.b. of the Utah Medicaid Provider Manual: TargetedCase Management, a licensed social service worker or a licensed registered nurse; or a licensedASUDC or licensed SUDC when targeted case management services are provided to individualswith a substance use disorder who have Traditional Medicaid.Non-licensed individuals must complete the training curriculum and certification requirementsspecified in Chapter 1-6 of the Utah Medicaid Provider Manual: Targeted Case Management; or8. registered nursing student engaged in activities constituting the practice of a regulated occupationor profession while in training in a recognized school approved by DOPL, or individual enrolledin a qualified substance use disorder counselor education program, exempted from licensure inaccordance with Section 58-1-307 of the Utah Code and under required supervision.C. In addition to the primary service providers specified above, individuals in C.1., C.2., andC.3., below, may also provide this service:1. Licensed mental health therapist practicing within the scope of his or her license in accordance withTitle 58 of the Utah Code:a. physician and surgeon or osteopathic physician engaged in the practice of mental health therapy;b. psychologist qualified to engage in the practice of mental health therapy;c. Certified psychology resident qualifying to engage in the practice of mental health therapy underthe supervision of a licensed psychologist;d. clinical social worker;e. certified social worker; or certified social worker intern under the supervision of a licensedclinical social worker;f. advanced practice registered nurse (APRN), either as a nurse specialist or a nurse practitioner,with psychiatric mental health nursing specialty certification;g. marriage and family therapist;h. associate marriage and family therapist under the supervision of a licensed marriage and familytherapist;i. clinical mental health counselor; orj. associate clinical mental health counselor under supervision of a licensed mental health therapist.2. An individual who is working within the scope of his or her certificate or license in accordance withTitle 58 of the Utah Code:a. Licensed APRN formally working toward psychiatric mental health nursing specialty certificationthrough enrollment in a specialized mental health education program or through completion ofpost-education clinical hours under the supervision of a licensed APRN with psychiatric mentalhealth nursing specialty certification;b. Licensed APRN intern formally working toward psychiatric mental health nursing specialtycertification and accruing the required clinical hours for the specialty nursing certification underthe supervision of a licensed APRN with psychiatric mental health nursing specialty certification;c. licensed physician and surgeon or osteopathic physician regardless of specialty, or other medicalpractitioner licensed under state law (most commonly licensed physician assistants whenpracticing within their scope of practice and under the delegation of services agreement requiredby their practice act); ord. licensed APRN or licensed APRN intern regardless of specialty.3. An individual exempted from licensure (as a mental health therapist), including:a. In accordance with Section 58-1-307 of the Utah Code, a student engaged in activitiesconstituting the practice of a regulated occupation or profession while in training in a recognizedUtah DSAMH Children and Youth Case Management Field Guide4
school approved by DOPL to the extent the activities are supervised by qualified faculty, staff, ordesignee and the activities are a defined part of the training program; orb. in accordance with Subsection 58-61-307(2)(h) of the Utah Code, an individual who wasemployed as a psychologist by a state, county or municipal agency or other political subdivisionof the state prior to July 1, 1981, and who subsequently has maintained employment as apsychologist in the same state, county, or municipal agency or other political subdivision whileengaged in the performance of his official duties for that agency or political subdivision.Supervision (when applicable) of individuals above must be provided in accordance with requirements setforth in Title 58 of the Utah Code, and the applicable profession’s practice act rule as set forth by theUtah Department of Commerce and found at the Department of Administrative Services, Division ofAdministrative Rules, www.rules.utah.gov/publicat/code.htm. In addition, all individuals providingtargeted case management services must know Medicaid regulations pertaining to targeted casemanagement as described in this provider manual.Targeted Case Management Training CurriculumTo meet the State DSAMH’s training standards, all non-licensed individuals will be required to:A. successfully pass a written examination which tests basic knowledge, attitudes, ethics, and casemanagement skills;B. successfully complete a DSAMH case management practicum; andC. successfully complete recertification requirements.In addition, all providers of case management services must know Medicaid regulations pertaining totargeted case management as described in Targeted Case Management for Individuals with SeriousMental Illness, Utah Medicaid Provider Manual. Division of Medicaid and Health Financing,July 2015.Utah DSAMH Children and Youth Case Management Field Guide5
Chapter II: Delivery of ServicesEthical GuidelinesIt is important that limits and boundaries be known and clear to the consumer and the casemanagement provider. Some limits originate with the LMHA/LSAA policy or the Code ofConduct (see Preferred Practice Guidelines, Provider Code of Conduct, and the NationalAssociation of Case Management Ethical Guidelines). These should be studied and understoodby each case management provider. Most limits and boundaries are maintained by soundjudgment of the case management provider. Case management providers must never, under anycircumstances, date or in any way encourage intimacy with cons
targeted case management services only to Medicaid recipients enrolled in the 1915(a) program. B. Primary providers of targeted case management services are: 1. licensed social service worker or individual working toward licensure as a social service worker in accordance with state law under supervision of a licensed mental health therapist; 2.
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