PURPOSE:   

To promote quality of service, the Aging and Disability Services Division (ADSD) has established service specifications that contain general guidelines. ADSD will use these service specifications as the basis for assessing program performance. The service specifications that each grantee must follow consist of GENERAL REQUIREMENTS, according to the funding source, and SERVICE-SPECIFIC REQUIREMENTS established for each funded service.

SERVICE DEFINITION:

This service is a process by which client needs and services are identified by the Aging and Disability Services Division, Elder Protective Services (EPS) staff during the course of an investigation. The case management provider is to ensure that identified needs are managed and that the care is coordinated and monitored to promote client safety and well-being.

SERVICE CATEGORIES AND UNIT MEASURES:

The following service category and unit measure established by the Administration on Aging (AoA) must be used to document the amount of service provided: 

Case Management:  Short-term assistance in the form of an assessment of needs, assistance with access to services, or care coordination in circumstances where the older person and/or caregiver are in need of ongoing protection that will require the provision of services by designated providers.  

One unit equals one hour of service.

GENERAL REQUIREMENTS: 

A.        Case managers are Licensed Social Workers, who must meet the requirements of NRS Chapter 641B - Social Workers, Advanced Registered Nurses (possess a master’s degree as a clinical nurse specialist or advanced practice RN) or individuals with case management expertise (work history or national certification as case manager).  

B.        Each grantee must follow ADSD policy regarding guardianship referrals, which requires that all referrals for guardianship are made to public guardians. Referrals to private guardians are not permitted. NRS 159.0535 requires that a proposed ward attend his/her hearing unless there is a certificate documenting the reason the proposed ward is unable to attend.

SPECIFICATIONS:

1.        Eligibility:

1.1       Client must be referred by the Elder Protective Services unit and be receiving protective services from the Aging and Disability Services Division. 

1.2       Referrals from the Clark County Senior Citizens Protective Service Program may also be served under the grant. 

1.3       The case management provider must indicate to the EPS Social Worker the projected time frame for the start of services.  

2.            Required Services: 

2.1       A written referral from the EPS social worker must be received by the authorized provider prior to services being initiated. A transfer conference by telephone or in person shall be held with EPS staff. The Aging and Disability Services Division EPS staff will provide a summary that will include:  identifying information, prior history, circumstances surrounding EPS involvement and family support information.  The case management provider will initiate contact with the client within three working days of the referral. 

2.2       The case manager will advocate on behalf of the client and/or client’s family to locate/follow-up with service providers and monitor service delivery to ensure that the client is not at risk of further abuse, neglect, exploitation or isolation.  

2.3       Cases may be re-opened (upon request from EPS), should the EPS unit receive additional allegations. An investigation will be completed and the case management provider will be consulted.  

2.4       Case management providers are mandated reporters of elder abuse, neglect, exploitation or isolation, and must report any new allegations that may surface during their involvement.  

3.      Optional Service: 

3.1       Transport of clients to apply for or receive needed services may be provided as part of the case management service. The grantee must verify that case managers maintain a valid Nevada driver’s license and automobile insurance per NRS 485.185.  All drivers must submit a copy of their driving record from the Department of Motor Vehicles, prior to hiring and annually, thereafter.  Copies of the driving records of each driver must be maintained on file.  A thorough fingerprint and background check must be completed on each case manager. 

4.            Case Record Requirements: 

4.1       A case record must be maintained on each referral for case management services and must contain the following: 

4.1.a     The referral form (EPS Case Management Services) is completed by the EPS social worker. It documents pertinent information regarding the client, prior history, circumstances surrounding EPS involvement, support systems and the requested services. 

4.1.b     A standardized assessment that provides a description of the home environment, the client’s physical and mental health and abilities.  

4.1.c     A care plan must be developed with the client/client’s representative that incorporates the EPS social worker’s requested services. The care plan must contain specific actions designed to meet the established goal of providing on-going protection of the client from abuse, neglect, exploitation and isolation. The care plan should include the projected type, amount, frequency, duration and source of services to be arranged or provided. The care plan must be signed and dated by the client and/or caregiver, if appropriate. A copy of the completed care plan must be provided to the client and/or caregiver, if appropriate.  The case management provider will send a copy of the completed care plan to ADSD within three working days of its completion. 

4.1.d     If the care plan goals are met and the client is no longer in need of case management service, the case will be closed. A written discharge summary will be forwarded to EPS within 10 days of the last contact/visit. The summary should include services provided, justification for discharge and total units of service.  

4.1.e     Amendments to the care plan must be made as necessary. 

4.2       A reassessment must be conducted at least every 90 days to assess any changes in the client’s physical health, mental health, emotional status and/or support systems. The reassessment must include the following: 

4.2.a     an evaluation of the services provided and the progress made towards reaching the objectives; 

4.2.b     an assessment of the need for continued case management services based on the evaluation of the services provided and the progress made toward the goal of on-going protection of the client; and 

4.2.c     a written summary of any progress to the client’s condition is sent to EPS every 90 days. 

5.            Special Compliance Requirement: 

5.1       Grantees must have current commercial and professional liability coverage as appropriate.