Case Management (90899-1)

Case management basically involves doing something for members because their mental illness prevents them from doing it themselves. Linkage to resources, advocacy, and monitoring are common examples. A defining characteristic of case management is that it never involves teaching members a skill. If you coach members through a phone call to housing, for example, or model how to behave during an interview, you're doing rehab. That's a different kind of service (90899-17) and has to be accounted for on a separate note.


These first 11 examples are monitoring services. The purpose of a monitoring service is to obtain the most up-to-date information we can about a member so we can provide the best possible services. Monitoring usually involves making observations and asking questions about topics that are relevant to the member's treatment. The goal is to be able to return to the clinic with a current snapshot of where the member is, so the team can review it and decide whether any changes need to be made.

Monitoring is just one form of Case Management. Other forms, like linkage and advocacy, are in the section immediately following this one.

G: Gary is a 36 y/o single Caucasian male diagnosed with schizoaffective disorder. He has significant impairments in social/communication skills due to A/H, lack of motivation and energy, low self-esteem, and social skill deficits secondary to his mental illness. I met with Gary at his R&B today to monitor progress towards his current objective, "Gary will improve his ability to manage depression as evidenced by spending at least 2 days a week in the company of others, away from his R&B."

I: I monitored progress towards this goal by asking Gary if he was spending time away from his R&B, in the company of others, and if so, to give me examples. Gary responded that he went to the store to get tobacco and rolling papers every week. I asked if this activity took all day and if he was in the company of others when he did it. He replied, "Well no, not really." I pointed out to Gary that he will be attending a group at TAO today and asked if he thought this was an example. He said "No, because it's with people like me." I gave Gary a ride to TAO so he could participate in the group and used the drive to continue monitoring progress. On the drive to TAO, I asked Gary to explain what he meant by "people like me". Gary stated that he was referring to people with a mental illness. I asked several more questions to clarify his thinking. Prompted him multiple times for more detail. Gary said he wanted "to be normal" and "be around normal people" and understood the objective as meaning he would spend time in the company of people "who aren't messed up". He said he did not think being around people like himself represented progress, even if he was away from his R&B.

P: Will share my observations in morning meeting. Will propose that assisting member with overcoming poor self-esteem and stigma associated with mental illness could help him accomplish this objective.

G: Marina is a 45 y/o divorced Hispanic female diagnosed with borderline personality disorder. She has significant impairments in multiple areas of functioning due to angry outbursts and difficulty regulating emotional responses (see current CFS and Care Plan). I met with Marina at her home today to monitor progress towards her current objective, "Marina will increase the number of situational triggers to anger that she can identify, from a baseline of 0 to a goal of at least 3, then develop a plan for what to do when she encounters them."

I: I monitored progress towards this goal by asking Marina to list the situations she has identified so far. She said she had identified "people making me feel disrespected" as a trigger but had not come up with anything more specific and concrete yet. Marina needed to go to TAO to participate in COEG group so I offered her a ride and used the trip as an opportunity to continue monitoring her progress. On the drive to TAO, I asked Marina to give specific examples of situations where people made her feel disrespected. She then came up with "when my son doesn't pay attention to me", "when people don't communicate things to me that I have a right to know", and "when I show up for group and they tell me it's cancelled." I questioned her as to whether she had come up with a plan for what to do in these situations, or was utilitizing any coping skills to deal with the anger she experiences in them. She replied, "No, not yet".

P: Will share my observations in morning meeting. Will suggest that assisting member with being more specific (e.g., examples of situations where she feels people have not communicated things to her) could help her develop a more effective plan for what to do (the second part of her objective).

G: Dennis is a 41 y/o single Caucasian male who experiences severe anxiety in public places and isolates in his home as a result. Dennis was assigned to my caseload earlier today and was at the program for an appointment with his doctor. I agreed to give him a ride home and used the trip as an opportunity to become more familiar with Dennis and his current situation, determine what progress he has made towards his treatment goals, and monitor the effectiveness of skills his previous PSC has been teaching him.

I: On the drive to Dennis’s home, I asked him questions about himself, how he is adjusting to his new R&B, if he has been utilizing any of the anxiety-reduction techniques he has been learning and if so, which ones seem to help; if he has made any friends yet (one of his current goals); if he is encountering any barriers that affect his ability to access treatment; and if he has been able to take his medications as directed (also a current goal). After we arrived at his R&B I continued monitoring his progress. Dennis shared that he was still having trouble remembering to take his medications, and that the wall calendar system proposed in his CP wasn’t working for him. He identified "keeping myself busy" as the coping skill he had been utilizing that seemed to work best for controlling his anxiety, but said he was having trouble coming up with things to do.

P: Will consult with TAO nurse about switching to pill cassettes or blister packs to help Dennis achieve his medication goal, and discuss with my team the possibility of adding volunteer work or increased group participation as an objective or self-intervention on Dennis’s plan.

G: Leonard is a 38 y/o single Hispanic male. Leonard has been stable at his current R&B since he moved in 2 months ago, but he has a long history of being exited from placements due to his paranoia, angry outbursts, and refusal to follow house rules. I met with Leonard and his R&B manager today to monitor his adjustment to his new placement.

I: Met with Leonard at his R&B. Asked him how he has been getting along with his new housemates, if he had any problems with anyone, and if so, if he felt the issue had been resolved. Inquired as to whether there were any other issues that could affect his placement, such as chores, curfew times, respect for his personal property and space, his food, etc. Leonard said the only issue was the R&B manager repeatedly telling him to do his bathroom chore, when he was already planning to do it and just waiting for it to be unoccupied. I thanked Leonard for his time and spoke with his R&B manager outside, without Leonard present. The manager explained that the bathroom chore is expected to be done in the morning, but that Leonard makes the excuse that "people are using it" and puts it off all day, sometimes not getting around to doing it at all. The manager said this is frustrating to him and the home's other residents, and he is considering asking Leonard to leave if he will not pull his weight.

P: Plan is to conduct a rehab service immediately following this CMS service to ensure Leonard understands that chores must be done at scheduled times, then provide suggestions on how he can do this, such as breaking his chore up into 3 or 4 parts, completing each part during periods when the bathroom is unoccupied. Afterwards, will call Leonard's R&B manager for updates 2-3 times per week and make weekly home visits to monitor Leonard's progress.

G: Carlos is a 26 y/o single Hispanic male who was hospitalized 3 weeks ago after threatening his step-father. Carlos’s symptoms are currently under control but when his A/H, paranoia, and delusions get worse, he becomes convinced people around him are plotting against him and responds with aggression and threats. This leads to police being called and Carlos having to be placed on a hold and hospitalized. I met with Carlos at his R&B today to monitor his stability and re-adjustment to the home.

I: Engaged Carlos in a conversation about how he is getting along with others now that he is back at his R&B, what his concerns are, and if he feels he needs any additional support. As we talked I watched for behaviors that are known to signal a deterioration in Carlos’s condition so that early intervention could take place if necessary. With Carlos these behaviors are abnormal vigilance (looking around the room as if anticipating a threat), restlessness, pacing, and saying things to himself that are barely audible to others. I did not observe any of these behaviors today. Carlos said he is feeling good and so far has everything he needs. He said he was taking his meds every day and showed me his pill bottles. He shared how he turns them upside down when he takes his morning dose, then right-side up again when he takes his evening dose. This helps him remember when he needs to take his meds, and when he has already taken them. I spoke briefly with his R&B manager, Gary, who said Carlos seems to be doing fine so far.

P: Will share my observations with my team and continue making weekly home visits to monitor stability.

G: Ruben is a 49 y/o separated Hispanic male. Ruben is diagnosed with diabetes and has been instructed by his PCP to measure his blood sugar and take his medications at specific times. Due to excessive anxiety when speaking with authority figures, Ruben does not ask his doctor questions and tries to give right answers when asked if he is following his doctor’s orders. As a result, Ruben is often confused about what he is supposed to do and when, but will not tell anyone. I met with Ruben at his R&B today to monitor adherence to PCP’s instructions.

I: Met with Ruben at his R&B. I asked him when he was using his glucometer, if he had set the time and date so the results would be easier to interpret (one of his doctor’s instructions) and when he was taking his Metformin. Ruben said he had misplaced his test strips but had not told anyone about it. He was out of alcohol wipes but said he was using Bactine instead. The date on his glucometer was still not set. Ruben said he usually took his Metformin at night but sometimes forgot the morning dose. I set the time and date on his glucometer and helped him locate his test strips, which were under his bed. Reviewed his doctor’s instructions on when he was supposed to measure his blood sugar and take his meds, and wrote it down on a large sheet of paper to help him remember.

P: Will relay today’s findings to TAO nurse for follow-up.

G: Bonnie is a 31 y/o separated Caucasian female. Bonnie interviews well and is able to get jobs easily, but her jobs are usually short-lived. Due to difficulty regulating emotional responses and sensitivity to perceived criticism, she gets into heated arguments with supervisors and co-workers and is usually let go within the first 3 months. Bonnie has been hired at a Jamba Juice store and is starting work tomorrow. I met with her at her R&B today to ensure she is prepared and has the resources in place to accomplish her current objective of maintaining part-time employment.

I: Questioned Bonnie to ensure she remembered decisions she had made with her team the prior week about disclosing her illness to co-workers, requesting and responding to feedback, coping with anger, tracking assigned work days, and getting to work on time. Bonnie listed them off and said she had them all memorized. I asked if she knew the bus route she would take, the pick-up times, transfer points, etc. Bonnie said she did. I asked if she had any other questions or concerns. She said she did not, that she felt prepared and excited about her new job.

P: Will relay my observations to Bonnie's team in morning meeting tomorrow, and meet with Bonnie weekly to monitor progress and identify any issues needing attention.

G: Marcela is a 29 y/o single Mexican female. Due to A/H and irritability, Marcela has had multiple conflicts with other residents at her R&B and is at risk of being exited. During these conflicts she yells at others to shut up and storms out of the room, slamming doors behind her. Her R&B manager has informed her that if this behavior continues, she will need to move. I went to her R&B today to monitor her stability in placement.

I: I met with Marcela in the patio area of her R&B, away from other residents. Marcela admitted that she loses her temper and tells people to shut up, but said it was because "they don’t understand what it’s like for me, with my voices." She explained that when multiple people try to talk to her at the same time, her voices get louder and more distracting, and it becomes impossible for her to understand what people are saying. She said the problem is even worse when the TV or loud music is playing in the background. I asked if she had shared this with her R&B manager and she said she had not. I asked if she was using the anger management skills she had learned. She said she was, but not until after the conflicts had already taken place. I then met with the R&B manager. He acknowledged that multiple people often tried to speak to Marcela at once, including himself, and that volume levels in the home were usually high. He offered to try speaking with Marcela outside, in a quieter place, and see if it helped.

P: Will brief my team on today's findings. Will continue making weekly in-person visits to Marcela's R&B to monitor the situation and maintain contact with R&B manager by phone between visits.

G: Carlos is a 26 y/o single Hispanic male who was hospitalized 4 weeks ago for DTO. Carlos’s symptoms are currently under control but when his A/H, paranoia, and delusions get worse, he becomes aggressive and makes threats, which often result in police involvement and hospitalization. I checked in with Carlos at his R&B today to monitor his stability and identify new needs, if any.

I: Observed Carlos for behaviors associated with previous relapses (restlessness, looking around the room, talking to himself, etc.) and did not observe any of these during my visit. Carlos's speech was clear and coherent, and he again described his method for tracking his medications, which he says is working for him. His R&B manager, Gary, reports that Carlos continues to do well and get along with others. I spoke to Gary and Carlos together and reminded them about Carlos's high vulnerability to stress, and asked them if they were following the team's recommendations for reducing it. They said they were, and offered examples of how they were doing it (keeping volume levels down, having Carlos room with a resident he gets along with, sticking to a set bedtime-uptime schedule, planning Carlos's days in advance, etc.).

P: Will share my observations in morning team meeting. Will continue weekly home visits to monitor stability and consult with house manager.

G: Bonnie is a 31 y/o separated Caucasian female. Due to difficulty regulating emotional responses and sensitivity to perceived criticism, Bonnie gets into arguments at work and has difficulty keeping jobs for more than a few months. She has a current objective of maintaining part-time employment and has been working at Jamba Juice for about 4 weeks now. I met with Bonnie at her R&B today to monitor her progress at her new job and identify any new needs she may have.

I: Engaged Bonnie in a discussion about her employment and how she felt things were going so far. We talked about her morning routine, if she was getting up and getting to work on time, and if she was showing up for work on the days she was scheduled. I asked if any new issues had come up that needed to be addressed. Bonnie said things were going as planned except for a day it rained and she got soaking wet at her transfer stop. I asked if she was having any conflicts at work and if so, how she handled them, and if she felt they were resolved. Bonnie said her job was fast-paced and required her to stay focused, so she wasn’t able to talk to her boss or co-workers very often except to ask for help. When she asked for help she received it, she said. Congratulated Bonnie for staying on her new job for a month and suggested she set a few minutes aside every day to talk to her supervisor and get feedback.

P: Will share my observations with Bonnie's team, assist her with getting a raincoat and umbrella for days it rains, and continue weekly visits to monitor progress.

G: Bonnie is a 31 y/o separated Caucasian female. Due to difficulty regulating emotional responses and sensitivity to perceived criticism, she gets into arguments at work and is usually let go within 3 months. Bonnie had maintained employment at a Jamba Juice store for about 8 weeks until yesterday, when she was told her services were no longer needed. I met with Bonnie at her R&B today to question her about what happened and determine if changes in her treatment or Care Plan may be indicated.

I: Bonnie explained that her supervisor was unappreciative of her work and favored the other employees because they flirted with him. She recalled an incident the prior week in which she had successfully de-escalated an angry customer, only to have her boss ignore her afterwards. She described the situation as "like sexual harassment" because in order to win favor with her boss she would have to pretend to be attracted to him. She believed her refusal to do this was the cause of her termination. I asked Bonnie if she had utilized any of the anger management skills she learned. She said she had (taking deep breaths, journaling after work), but they didn't help.

P: Plan is to discuss the situation with my team and consider updates to Bonnie's plan. Will consult with Team Lead and TAO therapist regarding a brief course of CBT, which has been under consideration as an intervention by the therapist for some time. Bonnie indicated she still wants to obtain part-time employment so her #2 objective will remain in effect on her current CP.




These examples involve advocacy and linkage to resources:

G: Linda is a 53 y/o separated Hispanic female. Linda was arrested in November 2018 on charges of possessing a controlled substance and violating a protective/stay-away order. She has a court hearing today that she must attend but due to anxiety, memory deficits, trouble concentrating, and lack of organizational skills, Linda has difficulty navigating unfamiliar places, asking for help, communicating, advocating for herself, and recalling important information she receives.

I: Met with Linda at her R&B and accompanied her to the hearing. On the drive there, I explained to Linda what the hearing was about, what she should expect, and how she should conduct herself in the courtroom. During the hearing, with Linda’s approval, I advocated on her behalf and answered questions about her disability and the treatment she is currently receiving. I asked questions Linda had that she was unable to articulate herself. I took notes on what was said during the hearing and what Linda needs to do next.  On the drive back to Linda’s R&B, I reviewed what was said during the hearing and what it meant for her, and clarified things she had difficulty understanding.

G:  Carl is a 57 y/o single Caucasian male. Carl has been having stomach pains for over a month and thinks he should see a doctor. Due to irritability and low tolerance for frustration, however, he will not attempt to call a doctor on his own.

I:  I obtained the MediCal Eligibility Response from Carl’s chart and called the number listed for PCP info (800) 463-0935. Talked with a representative, got the name and contact number for Carl’s PCP (Joey Santos, MD). Called PCP’s office and scheduled a new patient appointment for Carl for this Friday 8/17 at 3pm. Wrote the appt. time and date on a card for Carl to keep with him.

G: Adam is a 44 y/o single African American male. Due to ongoing issues with his housemates, including having his personal property damaged or destroyed on multiple occasions, Adam no longer feels comfortable at his current R&B and would like to relocate. Due to excessive anxiety when speaking with strangers, Adam needs assistance in finding a new place to live.

I: I met with Adam at TAO and talked with him about his preferences, where he would like to live, and what his expectations were. I explained what he would need to do, in terms of moving his belongings, giving notice to the R&B, and informing his rep payee. I then contacted 7 R&Bs, obtaining information on bed availability, house rules, curfew times, and the composition of the home (i.e., ethnicity and gender) per Adam's wishes. Facilitated communication between Adam and the R&B manager when he had questions he wanted to ask. We found 2 homes with upcoming vacancies that Adam felt he might like and set up appointments to go see them.

G:  Kay is a 52 y/o divorced Caucasian female.  Kay is homeless and needs to get into stable housing, but due to A/H and inability to concentrate, she has trouble following directions and filling out paperwork, and has still not applied for housing.

I:  Facilitated linkage to CoC by sitting down with Kay and completing an application on her behalf, including referral form, VI-SPDAT tool, and HMIS Intake and Enrollment Form. Will fax completed application to CoC and make a follow-up call afterwards.

G: Ruben is a 49 y/o separated Hispanic male. Ruben is diagnosed with diabetes and has been instructed by his PCP to follow a special diet and take prescribed medications. Ruben has stopped trying to follow the diet, saying it is too complicated for him to understand, and is not using his glucometer at the correct times. He also takes all his medication at night rather than twice a day as directed. Due to excessive anxiety when speaking with authority figures, Ruben gives what he thinks are right answers when he sees his PCP, and will not ask his doctor any questions. For this reason I accompanied Ruben to his doctor's appointment today to facilitate communication.

I: Met with Ruben at his R&B and accompanied him to the appointment. On the drive to the doctor's office, I explained to Ruben why it was important for him to be honest with his doctor rather than trying to please him by giving right answers. Explained that his doctor needed to have a clear picture of what was going on in order to make good decisions and provide good advice. At the appointment, I told Ruben's doctor about the problems he was having with the diet, with monitoring his blood sugar, and with taking his Metformin at the correct times. I then took notes on the information and suggestions Ruben's doctor gave him, and asked the doctor for several copies of the low-glycemic foods guide he gave Ruben in case Ruben misplaced his. On the drive back to Ruben's R&B, I summarized what the doctor told him and wrote down the main points so that Ruben could refer to them later.

G:  Sam is a 58 y/o divorced Caucasian male.  Sam has no source of income and needs to apply for SSI, but due to paranoia and delusional thinking he is afraid to call or go to SSA to begin this process.

I:  Facilitated linkage between Sam and SSA by accompanying him to the 900 S. Harbor Blvd. office and speaking with a representative. Sam signed an Appointment of Representative form so I could work directly with SSA on his behalf. The representative told me Sam had applied previously but had not responded to requests for more information so the claim had been closed. I began the re-application process by starting the Application for Supplemental Security Income (SSA-8000-BK). Completed 7 of 23 pages, need additional information to complete.

G: Steven is a 32 y/o single Caucasian male who is diagnosed with bipolar disorder. Steven has been trying to complete his BA degree for nearly ten years. He occasionally completes a class, but when he becomes manic, he enrolls in more classes than he can handle, stays up for days at a time immersed in school work, becomes exhausted, then begins dropping out of classes one by one until he has withdrawn from school entirely. This pattern of starting overly-ambitious projects and then abandoning them or being unable to follow through has repeated itself dozens of times. Steven is now registering for the Fall semester but concerned he will end up withdrawing again.

I: With Steven's approval I contacted the Student Coordinator at Cypress College and discussed Steven's special educational needs that resulted from his illness. He referred me to DSS (Disabled Student Support Services). I spoke with a representative at DSS on Steven's behalf and shared with her the problems related to his impulsive decision-making and lack of anticipatory planning. I worked with her to come up with solutions that would help Steven make better choices and get assistance and advice from a counselor on the campus. We set up an appointment for Steven to meet with a DSS worker at the college next week.


All PHI has been de-identified per HIPAA Privacy Rule