Case Management
in North Carolina
©
© Mary Thornton & Associates, Inc
1
Targeted Case Management
This is a Medicaid and state funded service
 Because of Medicaid’s involvement there
are extensive regulations that must be
followed
 Individual accountability is extremely
important
 TCM is a professional service with
appropriate supervision requirements.

A Very Simple Concept
The case manager should be the focus for
coordinating and overseeing the
effectiveness of all providers and programs
in responding to the assessed needs of the
individual.
 It is the individual’s access to care and
services that is the subject of their
management – not the individual.

What is the Starting Point?
Core Services
NC Definition
Federal DRA Definition
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Assessment
Case planning
Referral and related
activities
Monitoring and followup
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CM assessment
Person Centered Planning
Referral/linkage
Monitoring/follow-up
Continuum of Care: Different
Outcomes Expected
Treatment: relief of distress, reduction in
symptoms
 Crisis: resolution of crisis
 Rehabilitation: acquisition and maintenance
of life roles
 Case Management: referral and linkages to
necessary services and support; CM is
liaison to necessary services until Individual
is able to do on their own

Why Do We Have CM at All?
Many individuals with Serious Mental Illness or serious
addiction problems and/or intellectual disabilities have
multiple problems and unmet needs for services
 The system is fragmented with disparate resources not
working together
 These resources while not deliberate are structured so
that there are obstacles and barriers to getting services
 CM can facilitate access, negotiate services, and
coordinate multiple providers

What Works?
(1)
Outreach and education to individuals ,
their families and referral sources – not
many people know what targeted case
management is and its purpose
 Developing a trusting relationship
 Respecting the individual’s autonomy
 Prioritizing the individual’s self determined
needs – assisting them in generating their
own solutions

What Works?
Assistance in obtaining resources – note not just
services
– No overlaps, no misses
– Quickly and diligently
– Concrete and active
 Individualized Resource Development
 Appropriate caseloads – 1:50 in NC definition

What Works?

“ACT- like” or “CST-like” approaches
– Development of a coordinated Team
– Multi-disciplinary
– Access to specialists
– Long term if necessary – appeal of denials may
be necessary

Focus on specific and realistic targets
(1) Morse, Gary Ph.D., A Review of Case Management for People Who Are Homeless: Implications for Practice, Policy
and Research
Case Management Outcomes
in North Carolina
Single comprehensive PCP
 Linkages to appropriate medical assistance
 Linkage to natural supports as available
 Under 21 transition to alternative level of
care
 Less than 2 crisis episodes within past 3
months
 Increasing independence in managing own
care

Single Comprehensive PCP

Developed by CM with input from treatment team
and others involved with individual
– Initial plan: less detail because you do not know Individual
well and have not had time to do extensive research.
• The initial meeting should include education on crisis resources
and plan for linkage to crisis resources
– Subsequent plan (s): developed in partnership with
individual and all treatment/other providers - change as
change occurs – more detail added
– Goals and objectives are same for ALL treatment team
members
– CM – shows up as interventions only
Linkages to Appropriate
Medical Treatment
NC ahead of curve on requiring this
 Key strategic competency
 Who does it well? And how do they do it?

(Exercise on Best Practices for Coordinating with
medical providers)
Linkages to Natural Supports
as Available
Key to cost controls and developing
independence from mental health system
 CM must be assertive in defining the roles of
natural supports
 CM must be clear on expectations of natural
supports about CM (see next slide on what CM is
not)
 Natural supports can do a little or a lot –
remember to consider both –even a very little
helps

Under 21 Move from Residential
to Alternative In Community
Move to community based treatment and
lower, less restrictive level of care.
 Key cost control for system as residential
care expensive and for quality controls as
child is treated within their own community.
 You get paid for this work. You must include
the (at least) monthly face to face work as
well. See Implementation Update #83.
 How can this get done well? (Exercise on Best

Practices)
Less than 2 crisis episodes
within past 3 months
Breaking cycles
 How do CM’s do this?

– Advance directives
– Crisis plans
– Being assertive with treatment and rehab
providers –why isn’t what you are doing
working?

Need for expert clinical supervision to
accomplish this
Increasing independent in
managing own care
This is the bulk of the job for most CMs
 CMS considered that in the past the way
CM was conducted created greater
dependence on the CM – we need to
change this perception.
 What does this look like? Exercise: How Would

You Measure Greater Independence?
Design and Controls in NC

North Carolina designed CM with specific
controls on costs, determination of medical
necessity, and the quality of the CM
services. See handout.
General Medicaid Criteria

Services must be medically necessary:
– Determined by generally accepted North
Carolina community practice standards as
verified by independent consultants.
– Must have a current diagnosis
– Services must meet specific needs of individual
for prevention, diagnosis, treatment, or
rehabilitation
Eight Components of Medical Necessity

It treats a mental health or addiction condition/illness or
functional deficits that are the result of the mental illness/addiction
– (Note to be eligible for CM the MI/Addiction must be “serious)
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It has been ordered or prescribed
The service should be generally accepted as effective for the
mental illness being treated.
The individual must be willing to participate in treatment
The individual must be able to benefit from the service being
provided
It must be a covered service
It must be a medical, rehabilitative service – skilled and focused
There must be active treatment
19
How Does CM Become Medically
Necessary?
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Services must be medically necessary
Individual must be unable to access the services
and supports on their own – consider always
natural supports
The service must consist of one of 4 buckets of
activities
Must have an impact on client’s recovery or
recovery goals – watch for significance
Requires vigilance in determining if plan is being
implemented – active treatment concept
General Medicaid Criteria
Services must be individualized: watch for
documentation that is similar from service to
service or across your caseload
 Services are supposed to be specific and
consistent with the diagnosis/symptoms but CM
deals more with functional problems (e.g. inability
to access services and manage self-care) and the
complexity of the needs of the SMI/SED or
seriously addicted and so is often needed by
individuals with varied diagnoses.

– However services you refer to must meet this criteria
General Medicaid Criteria
Services cannot exceed the needs of the recipient
 Must be able to be safely furnished and no other
alternatives that are less restrictive and less
expensive are available
 Services cannot be provided or provided in a way
that is solely for the benefit of the individual, e.g.
home based therapy for someone who is not
home-bound and does not have transport or day
care issues.

CM Specific Medicaid Criteria
CM services can only be billed by an agency that is
certified by the state as a comprehensive service
provider called a CABHA
 Only one CABHA can provide and bill CM services
during the period of an authorization
 If more than one person in a family qualifies for CM
then we must assign one CM to provide CM
services to all family members
– This may mean reassignment of CM if the one
currently assigned is not trained or qualified to
provide services to a family.

CM Specific Medicaid Criteria

You can deliver services via face to face
contacts or on the phone
– Emails do not count
– Completing paperwork

You can consult and meet with persons other
than the Individual in care but these contacts
must be for the exclusive benefit of the
Individual
– Be very careful in situations with children and
their family members who are not recipients or
who are not eligible for CM
CM Specific Medicaid Criteria

You can deliver services in many different
locations – homes, offices, community, etc.
BUT
– You cannot deliver services to individuals who
are in jail or in secure juvenile detention centers
– You cannot deliver services to Individuals who
are inpatient settings with >16 beds that are
considered IMDs
– State funds can be used for juveniles in detention
and jails
CM Specific Medicaid Criteria

We will bill Medicaid on a weekly basis for all of the case
management services you, the CM provides
– The week begins on Sunday and goes to Saturday
– For this weekly rate we are required to provide all of
the CM services the Individual needs. In order to bill:
• You are required to provide at least one monthly face to
face visit for each of your cases
• You are required to provide one 15 minute visit weekly
this can be face to face or via phone. – you should make
arrangements for coverage during periods when you will
not be working
– However services must only be provided based on
client need, not the requirements for billing
CM Specific Medicaid Criteria
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There are certain services that include CM already and so a
separate CM cannot be assigned or provide services
There are other CM programs in the state. MH/SA TCM
cannot be provided and billed as well.
There are certain inpatient settings where Medicaid will pay
for both the inpatient services and case management as well –
but only for limited amounts of time and only in relationship to
discharge and transfer
There are certain other state programs that include some
elements of CM and must not be duplicated
SEE HANDOUT on Duplicate services
Services that Aren’t CM and
Aren’t Covered
Transportation time
 Transportation services
 Any treatment interventions

– If you meet credentials, experience, training to
provide other behavioral health services you can
but you must be careful to document and bill
these separately.
– If you provide other services, you must offer the
Individual a choice of providers and document
this discussion and the Ind. choice.
Services that Aren’t CM and Aren’t
Covered
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Any social or recreational activity
– You cannot supervise these activities and bill CM
either
Clinical and administrative supervision of staff
including team meetings without the
Individual present
 Writing reports: assessments, PCP, progress
notes
 Service record reviews.
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Case Management
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Key competencies:
– Understanding the community and available
resources
– Understanding the treatment resources available
• Who pays for what?
• What are conditions for payment?
– Understanding how to access benefits, financial
supports
– Being resourceful in developing natural and
community resources
– Ability to coordinate service delivery systems
– Knowing what case management can do and bill
for!
Clinical
Assessment
Meets Criteria
for TCM
Yes
Accepts
Referral for
TCM
Yes
Yes
Case
Management
Clinical
Assessment
Case Management in North Carolina
CM meets with
Individual
Confirm Need
and Accept CM
Submit ITR
with Supporting
Documentation
Authorization
No
Outpatient
Services
No
No
Referral for
Outpatient
Services
**Continued
Learning
Initial PCP
Person Centered
Plan**
Signed by MD for
Service Order
CM
Assessment
On-going
Yes
Authorization
No
Continuation of Assessment and PCP Process
CONTENT
EXPERT:
Consultation with
Providers/Systems
CONTENT
EXPERT:
Consultation with
Family
Continued
Consultation with
Individual
Revise PCP
PCP
Implemented
Continued
Services
Needed
Clinical Assessment
In the Individual’s CM records always
 Completed by someone who can DX and refer
 Documents medical necessity

– Eligibility criteria: (see handout)
• Diagnosis: note although regs state any diagnosis,
they also state services are for those with serious
MI/SED/Addiction –does this actually limit the
diagnoses?
• Pregnancy
• Functional criteria
• Location criteria for kids (residential)
• EPSDT determination of need
TCM in NC: Eligibility Criteria

Serious MI, SED, Addiction – see Handout
– Axis I or II (not only an ID) and pregnant
– Axis I or II (not only an ID), AND
• requires coordination among:
• 2 or more agencies (medical or non-medical) AND
• Unable to manage symptoms/ maintain abstinence due
to 3 unmet basic needs

OR under 21in resi and needs to move or 2 or more
crisis episodes within last 3 months or EPSDT order

Unsaid and important: they cannot do this
on their own/or with current supports
EPSDT: Early, Periodic, Screening,
Diagnostic and Treatment
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Special provision within Medicaid for recipients under 21 years
Allows for a screening examination by physician or other
licensed clinician and orders for services that are “medically
necessary to correct or ameliorated a defect, physical or
mental illness, or a (health)condition identified through a
screening examination”
Provider documentation of the screening needs to provide
support for the fact that the services are necessary and how
they will help to:
– Correct
– Improve
– Maintain
- Compensate
- Prevent worsening
- Prevent development of new problems
EPSDT: Early, Periodic, Screening,
and Treatment
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Recipients do not need to meet eligibility criteria and may
exceed service limitations on scope, amount, duration,
frequency, location, etc.
Services ordered must be medical and cannot be unsafe,
untested, ineffective.
EPSDT does not eliminate required authorizations for CM
Note: CMs need to be able to understand EPSDT for services
that they may be referring Individuals to and not just for the
purposed of getting authorizations for CM
Voluntary Service
CM cannot be used as a gate to other
services
 CM services require that the Individual
have freedom of choice of providers – even
if they are getting other services from you

CM Assessment

Important process for engagement
– Use motivational interviewing techniques

You do not need to reach a concensus
– You and individual do not need to agree –meet
the Individual at stage of acceptance or change
they are at
– Note areas of disagreement and leave door
open to revisit
Doesn’t need to be done at one visit
 Does need to confirm eligibility criteria

CM Assessment
Confirms information in clinical assessment
 No time frame in regs for when must be
completed. In our agency we expect……
 Gathers and considers all other assessment
information including medical information
 Note the regulations state that the CM
assessment is a integration of other assessment
information.

– Other assessments need to be reviewed, not
summarized and rewritten in a CM assessment
CM Assessment

Documents what is necessary for PCP: see
handout
– Needs: domain based
– Strengths: e.g. how much can they do
themselves, how fast can they learn
– Resources: currently or recently successful
– Preferences: linkages -want now, wait, not
want or how want and within what time-frame
– Goals: life and medically necessary Tx goals
CM Assessment

Initial assessment and PCP more likely based
on in-depth but not complete information
– Time needed to consult with other “Content
Experts” –called “new learning”
• providers/systems
• family, other natural suppports
Periodic reassessment needed but dates not
specified
 See handouts: Usual Activities, and Sample
Assessment

CM PCP
Comprehensive: covers preventative, diagnostic,
therapeutic, and rehabilitative services as well as
need for linkages to other systems, other services,
supports
 1-2 goals and 1-3 objectives for each
– Individuals valued outcomes or recovery goal
should be basis
– May need to add a treatment goal for medical
necessity purposes
– Interventions include treatment, rehab, case
management, other use of resources to reach
goals and objectives.

CM PCP
– This activity combines the treatment planning
activities with the service planning activities.
•
•
•
•
Consultation with Individual
Consultation with treatment providers
Consultation with family, other natural supports
Consultation with other community supports
– It is a process, not an event – engagement and
learning is on-going
– New learning should result in changes to the
plan
CM PCP – the Golden Thread

The eligibility criteria used to determine
medical necessity should be referred to –
e.g was it crisis episodes, residential
treatment, or what used to meet criteria. If
basic life needs – is this reflected in CM
assessment? Is it carried through in PCP?
– The PCP should focus on needs identified in
both the clinical assessment and the CM
assessment – golden thread is critical here.
Example: Recovery Goal and
Medically Necessary Tx Goal
Life Goal: I want to go back to work and
work with children especially
 Treatment Goal: Client will be able to
manage symptoms so that she can
successfully complete an educational
program that gives her the necessary
credentials to work with children.

Example cont.

Objectives:
– Client will be able to locate and successfully
attend a one day workshop on babysitting
– Client will apply and receive a library card and
will use the public library once weekly to read
or do research
Example cont.

Client will be able to locate and successfully attend
a one day workshop on babysitting
– Medication management services to address symptoms of
anxiety and paranoia
– Individual therapy weekly with focus on managing anxiety
and paranoia to allow for attending public ed activities
– Case management services:
•
•
•
•
•
•
Assist to make appointments
Review transportation needs
Prep for each appt with MD
Ensure any med changes communicated to all
Review monthly with Individual progress to obj.
Assist with locating and possibly scholarship for training
Another PCP Example:

Goal: Individual wants to move to apartment
– Link to therapy to manage symptoms
– Link to PSR program
• Medication compliance
• Managing an apartment and Safety
• Coping skills
• Travel training, etc.
– Link to local supports in neighborhood: police,
pharmacy, grocery, church
– Call bi-weekly to talk to PSR primary
– Review monthly with individual and plan for next
month
Service Order
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This is the PCP for now in NC –there is not a separate
document
Signed and dated signature
Order must include the date the service was ordered
Physician, licensed psychologist, PA, NP
– For all scope of practice must be considered
Must be in place on the day of or prior to first day of service
Based on clinical assessment
Valid from 1 yr from Date of Plan on PCP – this may not be
same date as authorization.
Re-ordered annually
Describe agency’s process for getting and filing these
documents and policy for substitutes.
Authorization

Authorization is required before this service
can be provided and billed
Authorizations are approved by a third party
reviewer to whom we submit the PCP, an ITR,
and other required supporting documentation.

See Agency Policy on Authorizations

Authorization

The authorization cannot be requested until
you have completed the initial PCP and the ITR
is completed:
– Because of the need for an authorization in
order to get paid, we will therefore require that
any referrals for services be dealt with
assertively – we would like you to take ____
days from the time of the initial appointment to
development of the PCP and documentation of
the ITR.
Authorization
The initial authorization period is for 90 days
 The authorization period should begins on
the date the provider requests the
authorization, but the approving agency has 5
days to make a decision.
 This information should be conveyed to the
Individual and their family so that they will
understand that there may be a short delay
between the initial meeting and the first
services being delivered.

Authorization
If there is an emergency or crisis situation
please contact your supervisor to get
permission to provide services prior to the
beginning of the authorization period.
 At the end of the first 60 days of the
authorization period, you should begin
thinking about whether a continuation
authorization will be needed.

– Follow agency policy for developing and
submitting the the reauthorization request.
Referral and Linkage

Referral vs linkage
– Differences support the CM outcome of
greater independence in self-management and
self-efficacy
– Referral: to direct to a source for help or
information
– Linkage: is not defined but does appear to
mean that the Individual is able to use the
referral independently or with natural or other
community supports – our goal is LINKAGE
Referral and Linkage

Case management can refer individuals to
services and supports regardless of who pays
for those supports
– Not limited to just Medicaid
– Can self refer (to our agency or to yourself if you
can provide additional services) but only if
Individual chooses freely. You must document this
discussion.
– Clients can choose to not take your advice or
agree to certain linkages or referrals
Referral and Linkage

Services CM refers to must be:
– Preventative: need documentation to support
– Diagnostic: keep this in mind if the Individual is
hitting a roadblock
– Therapeutic: defined as reducing distress by
treating or curing disease or disorders or their
signs and symptoms
– Rehabilitative: restoring what is lost. In psych
rehab is describes the acquisition or
maintenance of valued life roles.
Referral and Linkage

Two parts:
– Strategy: Planning for implementation of the various
parts of the plan: timelines, appointments, priorities,
etc.
– Implementation of the plan: Assistance with accessing
services and supports
Referral and Linkage

Critical planning activities:
– You cannot do everything at once but you and
Individual need to agree on what, when, who and
how – you need a timeline and this is a consensus
based decision
– Referrals are often much more successful if preplanning deals with necessary paperwork,
information that needs to be gathered, lists of
questions, etc. Also making sure there is agreement
on what the outcome of the visits will be. See
Handout
– Referrals more successful if the CM deals directly
with provider prior to appointment to discuss
coordination needs, the Individual’s recovery goals
Referral and Linkage

Making and Keeping Appointments
– Pay attention to the secretary
– Understand what has been said or written
– Think about other appointments you have
made so as to avoid a schedule conflict
– Remember to write down the appointment
– Remember to look at the calendar on the
designated day.
– Plan how you will get to the appointment
– Organize yourself to make sure you are
there on time.
– You may even want to make notes about the
things you will need to discuss at the
appointment
Referral and Linkage

Making and Keeping Appointments
– Very important: you must also be emotionally
ready and willing to keep the appointment
– You must be able and comfortable expressing
your issues and concerns to the provider
– You must be able to remember changes,
homework, advice and counseling, additional
activities you must undertake (e.g. lab work)
This sequence can be overwhelming. You are trying to intervene
where necessary, to provide supports where needed, and to
back off where the Individual can do by themselves or with
supports other than you.
Referral and Linkage

Critical implementing activities:
– Making appointments if Individual cannot
– Assisting the individual to get to the appointment
(remember transporting a individual is not a billable
activity)
– Talking with services and supports to describe what
the individual needs for this specific appointment
– Helping the individual to develop a list of the right
questions to get the information and services they
need –see Tools next slide
– Discussing with the individual how they will be
expected to participate and rules to follow
– Reminders about appointments
– Accompanying the individual to some appointments
to ensure proper and effective linkage and services.
Referral and Linkage
See tools for appointments
 These can be used with Individual, with
Individual and supports, or directly with
supports.

Texas Definition of Advocacy

Note advocacy is not used in federal
definition but….

Advocacy: asserting treatment needs; requesting
special accommodations; evaluating provider
effectiveness and compliance with agreed upon
treatment plan; requesting improvements and
modifications to ensure maximum benefit from
the services and supports.
Monitoring and Follow-up
Is the PCP being implemented? What not? Why?
What can be done?
 Are providers/system working in a coordinated
manner? If not, what does CM need to do to
improve? What communication strategy is being
used? What might work better?
 Is the plan working for the Individual? Is there
measurable progress towards recovery goals? If not,
why not? If yes, continue as is or change focus?
 Are there any changes to needs that require changes
to the PCP? Has the Individual’s status changed with
regards to eligibility?

Active Treatment = Integrated
Treatment
Active treatment, however, is not simply a
collection of disparate services: it is a
concept that embraces the whole range of
services a patient needs. The total effect
of active treatment is that the individual
components are integrated and directed
toward achieving the goals established in
each individual’s plan of care.
Monitoring and Follow-up
Remember - monitoring is of the case and its
implementation –not the Individual
 Where and with who does this analysis take place?
– Meetings/discussions with Individual
– Meetings/discussions with Providers and
representatives from involved systems
– Meetings/discussions with other natural and
community supports.
 Where is it documented?
– Progress or Case notes
– Changes to the PCP

Monitoring and Follow-up
If a service is denied, reduced, terminated,
suspended, etc. the CM will be responsible for
assisting the Individual to appeal the decision if they
choose to do so.
 See handout for Appeal Process information

Documenting Medically
Necessary Services
Telling a coherent, continuous,
reimbursable story in the medical
record.
67
Medicaid and Documentation

Golden Thread:
• Assessment:
– Biopsychosocial
– Psychiatric
– CM
• PCP
– Content: goals, objectives, interventions, etc.
– Emphasis on this acting as a road map for the provider and
consumer
– CM intervenes usually there is not a separate CM goal or
objective –they support them
Medicaid Documentation

Golden Thread Discussion:
• Case Notes
– Take your PCP with you so you remember what you are
doing and mean to accomplish
– You have a choice:
» Single full service note for each service
» On days with multiple services you can write one full
service daily note
• Case managers must write their own notes and
they must be individualized – no canned notes or
templates
The Client
Client currently experiencing auditory hallucinations that
she responds to frequently resulting in eviction from
apartment and 2 subsequent hospitalizations. Current
situation began 3 months ago when client stopped taking
medications. Client moved in with brother, currently on
meds but not stable and family (other treatment team
members) are concerned about client’s compliance as
client admits to frequent lapses in past. Client unable to
attend day programming and difficulty with social isolation
as a result. Client seeing psychiatrist bi-weekly to stabilize
medications. Brother wants Client out as soon as possible
but will provide some supports.
Assessment:
1. Client not stabilized on meds so currently still
symptomatic – continued linkage to psychiatry; client teaching;
family provide supports; higher level of care?
 2. Client not consistently medication compliant – research
other resources; client teaching
 3. Client socially isolated – not good as it adds to her
paranoia and bizarre behavior – research local supports;
family resources; other activities
 4. Unstable living situation jeopardizing community
placement – housing plan needed

Referral to Mental Health
Services for Tx Plan

Objectives:
– Client will stabilize on medications that will reduce symptoms so
that he can attend day treatment to reduce isolation and work on
recovery goal.
– Client will work with Rx Team (ID them) to recognize and then
minimize side effects from the medication that make compliance
more difficult. As measured by….
– Client will work with Rx Team to be able to connect the use of
medications with reduction in symptoms that risk his community
placement. As measured by…
– Family members (ID) and client will be able to identify meds, their
purpose and major side effects. As measured by….
Interventions:
Client will continue to see MD bi-weekly
– CM to meet with client bi-weekly for ½ hour prior to MD meeting to
ID questions
– CM will engage family to accompany client to medication appointments.
– CM will ID any med changes and ensure scripts filled and family notified
 Client and family will meet with nurse weekly for one hour for medication
education.
– CM will coordinate appointments and arrange transportation if
necessary
 Client will see current primary care doctor to make sure he/she knows
about psych meds and to screen for any contraindicating co-morbidities.
– CM will assist family/client to set up appointment.
– CM will accompany client to appt in order to advocate for appropriate
follow-up appointments and to assist client in explaining current
medications.
– CM will coordinate correspondence and communication between
psychiatrist and primary care MD,
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Medicaid Documentation

Content of Full Service Notes
– Technical requirements for all notes:
•
•
•
•
•
Recipient’s name
Medicaid ID number
Service Record number
Date of service
Place of service: be specific –if it takes place in a
car, list car for place of service
• Amount of time spent
• Signature, date of signature, and credentials
Medicaid Documentation

Content of Full Service Notes
– Content of Service Requirements
• Service provided: example in regs suggests that the
service should be listed as CM with type of CM also
listed, e.g. Case management/referral services. When
multiple types of CM services are provided this seems
impractical and it is not specifically required.
• Purpose of the contact: this is your agenda for the
contact. This should likely include some reference to
the PCP and the goal/objective being addressed
• Description of what you did – the case management
activities
• Description of results: Individual’s response, progress
made, next steps as a result, plan for next meeting
Progress Note



Goal: I want to stay in my own house; Objectives:
Consumer will determine housing choice.
Consumer will develop a plan for obtaining
permanent housing.
Reason for visit: Develop housing plan post transfer from
shelter
Consumer in crisis bed and is homeless with no
entitlements. Educated consumer about options for
housing if SSI is denied. Explored consumer’s preferences.
Consumer stated she would prefer SRO but is open to
other options. Agreed we will follow-up by end of week
to complete SSI application and discuss level of help
needed to locate housing.
Progress Note
Goal: I want to go back to work. Objective: Client
will be able to manage symptoms and reapply for
admission to PSR program part-time
Reason for visit: to check in with client about symptoms
Met briefly with consumer. She reports that she is stable
and taking her medications as prescribed. She agreed to a
follow-up appointment with me next week. She reported
no difficulties at this time. Does not appear to be
responding to hallucinations. Speech fluent, coherent.
Reports no side effects.
Progress Note
Goal: I want to go back to my own apartment
Objectives: Client will take first step to being
medication compliant: she will take all meds for
one week with prompting from brother
 Reason for visit: Prep for MD Appointment
 Met with brother and client to prepare for meeting with
MD tomorrow. Completed pre-appointment checklist and
I will fax to MD. Will call tomorrow to remind about
appointment. Brother will transport. Both said they felt
comfortable about what they need to accomplish. Brother
appeared to be less anxious about acting as advocate. We
will talk by phone tomorrow to follow-up on outcome.

Thanks!
© Mary Thornton & Associates, Inc.
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