2022 Edition

Case Management (CA-CM) 4: Service Planning and Monitoring

Each individual or family participates in the development and ongoing review of a service plan that is the basis for coordination and delivery of appropriate services and support.

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Individuals and families who receive Case Management services access and use resources and supports that build on their strengths and meet their service needs.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.  
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Service planning and monitoring procedures
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records


CA-CM 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s signature.

Fundamental Practice

CA-CM 4.02

The organization works in active partnership with individuals and families to:
  1. directly provide, or arrange for necessary services;
  2. provide case coordination and monitoring of services; 
  3. ensure that they receive appropriate advocacy support; 
  4. assist with access to the full array of services to which they are eligible; and
  5. mediate barriers to services within the service delivery system.
Examples: Personnel can help to engage and motivate individuals and families in this process by demonstrating: 
  1. sensitivity to their needs and personal goals;
  2. a non-threatening manner;
  3. respect for their autonomy, confidentiality, sociocultural values, lifestyle choices, and complex family interactions;
  4. flexibility; and
  5. appropriate boundaries.


CA-CM 4.03

The organization maintains a comprehensive, up-to-date list of community programs and services, and information on how to access them.


CA-CM 4.04

Service monitoring includes:
  1. confirmation, usually within one or two working days, that a service has been initiated as scheduled;
  2. verification, usually within 15 working days, that the service is appropriate and satisfactory;
  3. follow-up every three months; and
  4. immediate response to any complaints or problems that develop in the delivery of services or with the individual or family receiving services.


The organization should tailor the type and frequency of service monitoring according to the needs of individuals and families, frequency and intensity of service provided, and frequency of contact with informal caregivers and cooperating providers.


CA-CM 4.05

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly or more frequently depending on the needs of individuals and families, to assess:
  1. service plan implementation;
  2. the individual’s or family’s progress toward achieving goals and desired outcomes; and
  3. the continuing appropriateness of agreed upon service goals.


When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.


CA-CM 4.06

Workers and persons served, and their family when appropriate:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.