Targeted Case Management (TCM) Services
People receiving DDP 0208 Waiver services, or determined eligible for these services and age 16 or older are entitled to receive Targeted Case Management (TCM) services. This means if you fall into one of these categories you can receive TCM services right away, there is no waiting list.
TCM services are available across the entire state at no cost. These services are delivered primarily by AWARE, Inc. a contracted TCM provider. In some areas of the state these services may also be available from state-employed TCMs. People have a choice of who provides their TCM services.
People receiving TCM services can expect to meet with their TCM face-to-face, over the phone, or through other types of communication. The TCM will also interact, with your permission, with other people and providers that assist in meeting your needs in order to develop and coordinate a comprehensive plan of care.
If you are 16 or older, don’t currently have a TCM and have been found eligible, or need help in gathering information to submit for eligibility determination, please contact AWARE, Inc. at (406) 563-8117 to request the assistance of a TCM.
TCMs provide four primary activities:
- Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include
- gathering historical information;
- identifying the individual’s needs and completing related documentation; and gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual.
- Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that
- specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;
- includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and
- identifies a course of action to respond to the assessed needs of the eligible individual.
- Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.
- Activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individual’s needs, and which may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and including at least one annual monitoring, to determine whether the following conditions are met:
- services are being furnished in accordance with the individual’s care plan;
- services in the care plan are adequate; and
- changes in the needs or status of the individual are reflected in the care plan. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.
