Section 4.11. Case management services

Case management services shall be provided by a case manager who has a minimum of 1 year of experience in TBI case management, and shall include the following activities by the case manager:

(1) Monitoring the client’s progress with respect to the rehabilitation service plan and collaborating with the client or authorized representative, the client’s significant others and the rest of the treatment team in the development and modification of the rehabilitation service plan.

(2) Assisting the client in gaining access to services from which the client may benefit and for which the client may be eligible.

(3) Monitoring and evaluating the client’s progress in transitioning to living in a home or community setting and ensuring that any necessary supports are in place, or facilitating placement of the client in a long-term care facility.

(4) Determining that the client has fully transitioned to the home or community or has been referred to the appropriate long-term care facility.