2023 Edition

Case Management Definition

Purpose

Individuals and families who receive Case Management services access and use resources and supports that build on their strengths and meet their service needs.

Definition

Case Management services plan, secure, coordinate, monitor, and advocate for unified goals and services with agencies and personnel on behalf of individuals and families.

Intensive Case Management services are provided by a case manager who has an established relationship with the person served and delivers and/or coordinates a comprehensive array of services through ongoing support and frequent contact.
 
 

 

Note:COA's Case Management standards apply to stand-alone case management programs. Agencies that provide Foster Care Case Management Services are accredited under COA's Family Foster Care and Kinship Care (PA-FKC) standards and not Case Management.


Note: Please see PA-CM Reference List for a list of resources that informed the development of these standards.  


Note:For information about changes made in the 2020 Edition, please see the CM Crosswalk.  

2023 Edition

Case Management (PA-CM) 1: Person-Centered Logic Model

The agency implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.

Note: Please see the Logic Model Template for additional guidance on this standard.  

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence On-Site Evidence On-Site Activities
  • See program description completed during intake
  • Program logic model that includes a list of outcomes being measured
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
 

PA-CM 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, agency, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered); 
  5. desired outcomes (i.e. the changes you expect to see in service recipients); and
  6. expected long-term impact on the agency, community, and/or system.

Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA’s PQI Tool Kit for more information on developing and using program logic models.

Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to: 
  1. needs assessments and periodic reassessments; and
  2. the best available evidence of service effectiveness.  
 

PA-CM 1.02

The logic model identifies client outcomes in at least two of the following areas:
  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation; 
  5. quality of life; 
  6. achievement of individual service goals; and 
  7. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PA-PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 

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2023 Edition

Case Management (PA-CM) 2: Personnel

Case management personnel have the competency and support needed to access, coordinate, and provide services and meet the needs of individuals and families.
Interpretation: Competency can be demonstrated through education, training, or experience. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence On-Site Evidence On-Site Activities
  • List of program personnel that includes:
    • Title
    • Name
    • Employee, volunteer, or independent contractor
    • Degree or other qualifications
    • Time in current position
  • See organizational chart submitted during application
  • Table of contents of training curricula
  • Procedures or other documentation relevant to continuity of care and case assignment
  • Sample job descriptions from across relevant job categories
  • Documentation tracking staff completion of required trainings and/or competencies
  • Training curricula
  • Caseload size requirements set by policy, regulation, or contract, when applicable
  • Documentation of current caseload size per worker
  • Interviews may include:
    1. Program director
    2. Relevant personnel
  • Review personnel files
 

PA-CM 2.01

Case managers are qualified by:
  1. a bachelor’s degree in a human service field;
  2. case management certification; or
  3. a bachelor’s degree in a field other than a human service, with appropriate experience.
 

PA-CM 2.02

Supervisors of case managers are qualified by:
  1. an advanced degree in social work or a comparable human service field and a minimum of two years’ experience in direct services or case management;
  2. a bachelor’s degree in a human service field and four years' experience in direct services or case management; and/or
  3. certification, registration, or a license to practice in case management and four years' experience in direct services or case management.
 

PA-CM 2.03

Case managers receive training on, or demonstrate competency in, the following topics:
  1. coordinating services as part of a team;
  2. linking service recipients, and making referrals to, community services; and
  3. knowledge of public assistance programs, eligibility requirements, and benefits.
 

PA-CM 2.04

The agency maintains service continuity for individuals and families by:
  1. assigning a worker early in the contact, when appropriate; and
  2. minimizing the number of workers assigned to persons served over the course of their contact with the agency.
 

PA-CM 2.05

Caseload sizes are sufficiently small to permit case managers to respond flexibly to differing service needs of individuals and families, including frequency of contact, and to support the achievement of client outcomes.

Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; and
  3. service volume, accounting for assessed level of needs of persons served.
2023 Edition

Case Management (PA-CM) 3: Intake and Assessment

The agency's intake and assessment practices ensure that individuals and families receive prompt and responsive access to appropriate services.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Screening and intake procedures
  • Assessment and re-assessment procedures
  • Copy of assessment tool(s)
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
 

PA-CM 3.01

Individuals and families are screened and informed about:
  1. how well the request matches the agency's services; and 
  2. what services will be available and when.
NA Another agency is responsible for screening, as defined in a contract.
 
Fundamental Practice

PA-CM 3.02

Prompt, responsive intake practices:
  1. include screening for level or intensity of service;
  2. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  3. give priority to urgent needs and emergency situations;
  4. support timely initiation of services; and
  5. provide for placement on a waiting list or referral to appropriate resources when individuals and families cannot be served or cannot be served promptly.
 

PA-CM 3.03

Individuals and families participate in an individualized, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. updated as needed based on the needs of persons served; and
  3. focused on information pertinent for meeting service requests and objectives.

Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

 

PA-CM 3.04

The agency conducts the assessment in-person, in a place of the individual’s or family's choice, when possible, and: 
  1. includes assessment of natural supports and helping networks; and 
  2. promptly provides or makes arrangements for specialized assessments, as needed.
 

PA-CM 3.05

Individuals and families participate in a formal re-assessment annually or more frequently based on the following criteria:
  1. within five working days of a precipitating event;
  2. when there is a change in their status or circumstances, or a new issue arises; and
  3. within 48 hours of notification that hospital or institutional discharge is imminent.
Interpretation: An agency that, due to contractual requirements, is unable to conduct event-based re-assessments according to these timeframes should modify them to meet the needs and goals of persons served.
2023 Edition

Case Management (PA-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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VIEW THE STANDARDS

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence On-Site Evidence On-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
 

PA-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

PA-CM 4.02

The agency 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.
 

PA-CM 4.03

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

PA-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.
Interpretation: The agency 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.
 

PA-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.
Interpretation: 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.
 

PA-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.
2023 Edition

Case Management (PA-CM) 5: Intensive Case Management

Intensive case management services connect individuals and families to a coordinated, comprehensive array of services that meet their ongoing needs.
NA The agency does not provide Intensive Case Management Services.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Client contact procedures
  • Intensive case management caseload size requirements set by policy, regulation, or contract
  • Documentation of current caseload size per worker
  • Resume or formal agreement with psychiatrist or qualified medical personnel
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
 
Fundamental Practice

PA-CM 5.01

As needed, the agency directly provides, or formally arranges for, and coordinates:
  1. 24-hour crisis intervention;
  2. psychiatric services;
  3. housing services;
  4. medical and dental services;
  5. alcohol and other drug education and treatment;
  6. public assistance and income maintenance;
  7. family support services;
  8. vocational training and job placements; and
  9. transportation.
 

PA-CM 5.02

Case managers help individuals and families strengthen and manage the quality of their lives by:
  1. initiating change agent activities;
  2. teaching problem solving skills; and
  3. modeling productive behaviors.
 
Fundamental Practice

PA-CM 5.03

Caseload sizes range between 10 and 15 cases depending on the needs of individuals and families, the goals sought by the intervention, and the frequency of contact.
 

PA-CM 5.04

The agency makes direct contact with the individual or family at least four times per month.
 
Fundamental Practice

PA-CM 5.05

A psychiatrist or another qualified health practitioner with experience appropriate to the level and intensity of service and persons served, is responsible for the psychiatric aspects of the program.
Interpretation: The agency may use a consulting psychiatrist or community mental health center with which it has a formal agreement for psychiatric consultation.
2023 Edition

Case Management (PA-CM) 6: Case Closing and Aftercare

The agency works with individuals and families to plan for case closing and, when possible, to develop aftercare plans.

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence On-Site Evidence On-Site Activities
  • Case closing procedures
  • Aftercare planning and follow-up procedures
  • Relevant portions of interagency agreement, as applicable
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
 

PA-CM 6.01

Planning for case closing:
  1. is a clearly defined process that includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, persons served, and others as appropriate to the needs and wishes of the consumer.
 

PA-CM 6.02

Upon case closing, the agency notifies any collaborating service providers, as appropriate.
 

PA-CM 6.03

If an individual or family has to leave the program unexpectedly, the agency makes every effort to identify other service options and link them with appropriate services.
Interpretation: The agency must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits are denied or have ended and who are in critical situations.
 

PA-CM 6.04

When appropriate, the agency works with persons served and their family to:
  1. develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and facilitates the initiation or continuation of needed supports and services; or
  2. conduct a formal case closing evaluation, including an assessment of unmet need, when the agency has an interagency agreement that does not include aftercare planning or follow-up.
 

PA-CM 6.05

The agency follows up on the aftercare plan, as appropriate, when possible, and with the permission of the individual or family.
NA The agency has an interagency agreement that does not include aftercare planning or follow-up.

Examples: Reasons why follow-up may not be appropriate include, but are not limited to, cases where participation is involuntary, or where there can be a risk to persons served such as in cases of domestic violence.
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