Case Management (MAI)

A range of client-centered services that links clients and other family members with health care, psychosocial and other services to insure timely, coordinated access to medically appropriate levels of health and support services, continuity of care, ongoing assessment of the client’s and other family members’ needs and personal support systems, and inpatient case management services that prevent unnecessary hospitalization of that expedite discharge, as medically appropriate, from inpatient facilities. If a referral includes a consultation, then it is considered an encounter.

Key activities include:

• Initial comprehensive and ongoing assessment of the client’s and other family members’ needs and personal support systems
• Development of a comprehensive, individualized service plan
• Coordination of the services required to implement the plan (including making appropriate referrals); client monitoring to assess the efficacy of the plan
• Periodic re-evaluation and revision of the plan as necessary over the life of the client to ensure continuity of care. May include client-specific advocacy and/or review of utilization of services.