Chapter 40: Case Management

Chapter 40: Case Management

·  40.1 Case Notes

o  40.1.1 Purpose

o  40.1.2 What to Include

o  40.1.3 What Not to Include

o  40.1.4 Preliminary Assessment

o  40.1.5 Extended Evaluation/Trial Work

o  40.1.6 Comprehensive Assessment

o  40.1.7 Active Services

o  40.1.8 Employment

o  40.1.9 Outcome—Not AcceptedClosure before Application/Closure after Application

o  40.1.10 Outcome—Not Rehabilitated Unsuccessful Closure before Plan Initiated/Unsuccessful Closure after Plan Initiated

o  40.1.11 Outcome—Rehabilitated Successful Closure

o  40.1.12 Post-EmploymentClosure

o  40.1.13 Outcome—Post-Employment Closure Completed

o  40.1.14 E-Mmail Messages from Consumers

·  40.2 Case Folder Organization

o  40.2.1 Guidelines on Use of Two-Sided or Six-Sided Case Folders

·  40.3 Time in Status

o  40.3.1 Information on the Report

o  40.3.2 Benchmark Time Frames

o  40.3.3 Required Actions

·  40.4 Guidelines for Referral and Transfer of Cases

o  40.4.1 Introduction

o  40.4.2 Transfer of Case Folder to Another VR Caseload

o  40.4.3 Procedure for Transfer

o  40.4.4 Procedure after Transfer

o  40.4.5 Supervisory Action

o  40.4.6 Referrals from the Children's Program

o  40.4.7 Transfer of College Students to College-Based VRC

o  40.4.8 Transfer of Other College Students

o  40.4.9 DBS/DRS Agreement for Serving Consumers

o  40.4.10 Referrals from the IL Program

·  40.5 Adjusting the Phase of a Previously Closed Case

o  40.5.1 Phase Adjustment

·  40.6 Updating Case Recording

o  40.6.1 Purpose

o  40.6.2 Documentation Guidelines

o  40.6.3 Procedure for Updating

o  40.6.4 Procedures for Updating Other Caseload Materials

·  40.7 Quality Assurance

o  40.7.1 Compliance

o  40.7.2 Quality

o  40.7.3 Consumer Satisfaction Surveys

·  40.8 Caseload QA

o  40.8.1 Caseload Review

o  40.8.2 Case Review Selection Using the Risk Assessment Process

o  40.8.3 Completing a Caseload Inventory

40.1 Case Notes

40.1.1 Purpose

Case notes document the VR process from the initiation of consumer contact through to the eventual closure of a case. They are written in such a manner to allow the VRC or any DBS staff to have a clear understanding as to consumer interest, informed choice, rationale for decision making, as well as significant interaction between the counselor and consumer and critical steps in advancing the rehabilitation process.

Note: for information on how to access and use case notes in TWorksselect case notes link in the TUG.

40.1.2 What to Include

(Revised 01/10)

Case notes are used to document

·  routine contacts with consumers at least as often as agreed upon by the consumer and the counselor;

Note: Contact at least once every 90 days is recommended.

·  an explanation of any time extension beyond the allowed 60 calendar days to determine eligibility;

·  the consumer's progress or lack of progress toward achieving the vocational goal;

·  the IPE annual review results if there are no substantial changes in services, responsibilities, or other areas in the existing IPE, noting that the consumer and counselor are in agreement that no changes are needed;

·  a summary of the contents of medical or postoperative reports,

·  analysis of information and any conclusions reached from reports or data;

·  clarification of vague or inconsistent information found elsewhere in the case file;

·  "no- shows" of providers or consumers as required in the TUG;

·  a concise history from referral to closure; and

·  all case information given to others who are helping the consumer achieve a planned outcome.

When preparing case notes, record significant information (what, who, when, where) and decisions (what, how and why) when they are not obvious from other case file documentation. Examples of information to include in regular case notes are:

·  consumer perceptions and expectations

·  counseling efforts

·  rationale for providing services in special or exceptional situations

·  discrepancies in medical, diagnostic, or other recommendations and counselor decisions/actions to resolve them

·  loss of contact with consumer and efforts/actions taken to restore contact

·  significant changes in consumer situation (disability, family, financial situation, etc.) which might affect the program

·  changes in the availability of comparable services and benefits and efforts to secure these benefits

·  employment assistance activities (including employer contacts made on behalf of consumer)

·  summary documentation of reports contained in the paper case folder.

40.1.3 What Not to Include

Do not include the following in a case note:

·  information duplicated in other sections of TWorksReHabWorks or on other forms or reports in the paper case folder unless

o  the information is significant to that case note. If so, summarize the information; or

o  the case note is a summary, such as in

§  a preliminary assessment,

§  a comprehensive assessment, or

§  an outcome case note.

·  any reference to the consumer's HIV status;

·  statements referring to a consumer's physical or psychiatric diagnosis unless

o  supporting documentation is in the case folder, and

o  the reference is relevant to that case note.

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40.1.8 Employment

In the case notes, the counselor should note any additional information that has not been placed in the employment section of TWorksReHabWorks, such as:

·  who placed the consumer

·  any needed accommodations

·  any upcoming concerns or problems

·  any other relevant information

·  the need for possible post employment services.

40.1.9 Outcome—Not AcceptedClosure before Application/Closure after Application

For applicants closed as not accepted, document in an Outcome case note that the consumer was sent a letter for not accepted (DARS24055102) or (DARS23025201) if being closed as too severe from extended evaluation/trial work) informing them that their case is being closed. A DARS24055102 is not required for cases being closed from initial contact, since they are being closed prior to completing an application for services.

40.1.10 Outcome—Not RehabilitatedUnsuccessful Closure before Plan Initiated/Unsuccessful Closure after Plain Initiated

For cases closed as not rehabilitated (unsuccessful), document in an Outcome case note that the consumer was sent an unsuccessful letter (DARS24085203) informing them that their case is being closed.

If the closure reason is unable to locate, then refer to Unable to Locate or Moved Out of State Guidelines regarding methods of attempting to locate the consumer. Document these attempts in case notes.

40.1.11 Outcome—RehabilitatedSuccessful Closure

For cases closed rehabilitated (successful):

·  document in an Outcome case note that the consumer was sent a successful letter (DARS23065202) or

·  for consumers who are going immediately from rehabilitation into post-employment a (DARS23075209) informing them that their case is being closed.

40.1.12 Post-EmploymentClosure

The Post-Employment Closure case note must document that they are eligible for services in that:

·  a continuing eye condition that meets the DBS definition of a visual impairment

·  issues that are affecting consumer’s ability to maintain employment after being closed as rehabilitated and

·  the rationale for re-opening of the case for post-employment services.

40.1.13 Outcome—Post-Employment Closure Completed

For cases closed in Post-Employment Closure Completed, document in an Outcome case note that the consumer was sent a letter (DARS24095209) informing them that their case is being closed.

40.1.14 E-Mmail Messages from Consumers

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40.2.1 Guidelines on Use of Two-Sided or Six-Sided Case Folders

(Revised 07/06, 03/12)

Documentation maintained on ReHabWorksTWorks should not be duplicated within the case file.

Documentation of service delivery, including contact reports and other reports, etc., are maintained in either a two- or six-sided case folder. Each region may determine which type of folder is used. Regardless of which type of folder is used, the folder order listed below must be followed.

Documentation Order

Each section of the case folder should be organized so that initial documents are on the bottom and most recent on the top unless otherwise specified. As a result of the volume of information often contained in the six-sided case folder, dividers should be used to section off certain areas of documentation. This makes the information easier to access on a routine basis.

Two-Sided Case folder

·  Side 1: (top to bottom)

o  Invoices with references to PO numbers. Do not include a copy of the PO.

·  Side 2: (top to bottom)

o  Copy of closure letter or page from ReHabWorks to facilitate case-file purging.

o  DARS5051, Application for Services (only if a paper application is taken) or DARS5052, Application Statement for VR only if needed for release or paper application is taken and a pseudo PIN is used in ReHabWorks with signature.

o  Signed IPEs (DARS5151, DARS5152) only if a pseudo PIN is used with a signature.

o  Optional: DARS5060, Permission to Collect Information or DARS1514, Permission to Collect Information and DARS5061, Notice and Consent for Disclosure of Personal Information or DARS1517-1, Notice and Consent for Disclosure of Personal Information.

o  Assessment reports in chronological order by date received (for example, medical reports, training reports, etc.).

o  General correspondence in chronological order to include such things as letters to and from family; letters to and from vendors, Social Security packets, etc.

o  Copy of closure letter or page from TWorks (e.g. Ineligibility, Successful, and Unsuccessful closures) to facilitate case-file purging.

o  Application for Services (DARS2401) only if paper application is taken or Application for Services Vocational Rehabilitation Program (DARS2490-1) only if needed for release or paper application is taken and a pseudo PIN is used in TWorks with signature.

o  Signed IPEs (DARS2303, DARS2304) only if a pseudo PIN is used with a signature.

o  Optional: Permission to Collect Information (DARS2402 [available only in TWorks or use DARS1514, Permission to Collect Information]) and Authorization to Release Information (DARS2403 [available only in TWorks or use DARS1517-1, Notice and Consent for Disclosure of Personal Information]).

o  Assessment reports (chronological order by date received), i.e., medical reports, training reports, etc.

o  General correspondence (chronological order) to include such things as letters to and from family; letters to and from vendor, Social Security packets, etc.

Six-Sided Case Folder—-VR

Side 1: Basic Information

Basic information is placed in the following order from bottom to top chronologically (most recent on top) and separated by a divider:

·  old contact reports (CB-4) in chronological order, most recent on top, documenting activity from intake through closure and if necessary, post-employment;

·  DARS5051, Application for Services, only if paper application is taken or DARS5052, Application Statement for VR (only in ReHabWorks), only if needed for release or paper application is taken and pseudo PIN is used in ReHabWorks with a signature;

·  DARS5060, Permission to Collect Information and DARS5061, Authorization to Release Information, (or DARS1514, Permission to Collect Information) (optional);

·  DARS5151, Individualized Plan for Employment (IPE) or DARS5152, Individualized Plan for Employment (IPE) Amendment only if a pseudo PIN is used in ReHabWorks with a signature;

·  Consumer Data Sheet (CDS) or Initial Contact Page from ReHabWorks (optional); and

·  copy of closure letter or page from ReHabWorks (for example, Ineligibility, Successful, and Unsuccessful closures) to facilitate case-file purging.

·  old contact reports (CB-4) in chronological order, most recent on top, documenting activity from intake through closure and if necessary, post-employment;

·  DARS2401, Application for Services, only if paper application is taken or DARS2490-1, Application for Services Vocational Rehabilitation Program only if needed for release or paper application is taken and pseudo PIN is used in TWorks with a signature;

·  DARS2402, Permission to Collect Information and DARS2403, Authorization to Release Information, (or DARS1514, Permission to Collect Information) (optional);

·  IPEs [DARS2303, Individualized Plan for Employment (IPE), DARS2304, Individualized Plan for Employment (IPE) Amendment] only if a pseudo PIN is used in TWorks with a signature;

·  Consumer Data Sheet (CDS) or Initial Contact Page from TWorks (optional); and

·  copy of closure letter or page from TWorks (for example, Ineligibility, Successful, and Unsuccessful closures) to facilitate case-file purging.

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40.3 Time in Status

40.3.1 Information on the Report

The dDetail Time in sStatus report in ReHabWorksTWorks assists in tracking consumer progress toward achieving the employment goal. This report is located in the main menu of TWorksReHabWorks under Reports.

TWorksReHabWorks additionally will provide system generated actions requiring the counselor to document that the action has been completed or canceled. It benchmarks the cases that have exceeded the recommended time in a particular status. These benchmarks are not intended to limit services in any particular status, but to assist in insuring that consumers are making progress in the rehabilitation program.

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40.5 Adjusting the Phase of a Previously Closed Case

40.5.1 Phase aAdjustment

Phase adjustment – reestablishes a case from closure phase to active phase (plan initiated). Only 26 and 28 closures can have their phases adjusted. This adjustment includes removingal of closure information and changing the closure flag on employment information from "yes" to "no."

Unsuccessful Case Closure

·  If (status 28) after initiation of an IPE, the Field Director approves phase adjustment of a case that has been closed one year or less, then

o  adjust the phase (back the case to active status), and

o  enter a case note of explanation and approval action delegated to the Field Director.

System Feature—Data entered at the time of closure is lost except for employment information. Closure flag in employment information is changed from "yes" to "no."

Successful Case Closure

·  If (status 26) in error and Field Director approves the phase adjustment, then

o  adjust the phase (back the case to plan initiated), and

o  enter a case note of explanation and approval action delegated to the Field Director.

System Feature—Data entered at the time of closure is lost except for employment information. Closure flag in employment information is changed from "yes" to "no."

If employment information is obtained on a consumer with a case previously closed unsuccessful after provision of services,:

·  review the case to ensure all criteria for successful closure are met (see Successful Closures),. and

·  and adjust closure to successful.

for specific information regarding TWorks, select Phase Adjustment in the TUG.