"Home Is Where The Care Begins"

Carolinas Home Care Agency, Inc.  

Mental Health/Substance Abuse Targeted Case Management (MH/SA TCM)

Carolinas Home Care Agency, Inc., offers MH/SA TCM which is a service for adults and children age three and older who have a serious emotional disturbance, mental illness, or a substance related disorder and for recipients who have a serious emotional disturbance, mental illness, or substance related disorder and are pregnant. The TCM/SA case manager/Qualified Professional is required to coordinate and communicate with Community Care of North Carolinas (CCNC) if the recipient is enrolled in CCNC the recipient’s primary care physician and the recipient’s OBGYN as necessary.

MH/SA TCM is an activity that assists persons to gain access to necessary care: medical, behavioral, social and other services appropriate to their needs. Case management is individualized, person centered, empowering, comprehensive, strengths-based, and outcome focused. The functions of case management include:

  1. Case Management Assessment
  2. Person Centered Planning
  3. Referral/Linkage
  4. Monitoring/follow-up


Case Management Assessment shall include

Carolinas Home Care Agency, Inc. comprehensive and culturally appropriate case management assessment documents a recipient’s service needs, strengths, preference, resources, and goals to develop a Person Centered Plan. The case manager/Qualified Professional shall gather information regarding all aspects of the clients which includes but limited to psychosocial, behavior, medical, physical/functional, financial, social, cultural, environmental, legal and vocational/educational areas.

This case management assessment integrates all current assessments including the comprehensive clinical assessment, psychological assessments, and medical assessments, including assessments and information from CCNC (if applicable) and primary care physician. This case management assessment shall also include early identification of conditions and needs for prevention and amelioration.

In addition, the case management assessment involves consultation with other natural and paid supports such as family members, medical and behavioral health providers and educators to from a complete assessment. The case management assessment includes periodic reassessment to determine whether a recipient’s needs or preference have changed. Reassessment occurs at least annually as part of the Person Centered Planning Process.

Person Centered Planning

The goal of person centered planning is to assist the person to obtain the outcomes/skills/symptom reduction that they desire by listening to the person, family and achievement of their goals. A person centered plan is revised as the individual’s needs, preferences and goals change.

Person centered planning is at the center of self-management and self-direction. Information shall be gathered from the individuals, family, friends, other providers, and case managers. The case manager uses a variety of person-centered practice tools with the person to whom the plan belongs and other identified who know the recipient best to determine what is important and for that person.

The tools are also used to figure out from the perspectives of the recipient, the family and/or paid providers what is currently working or not working, what makes sense or doesn’t make sense, what needs to be maintained or changed for the individual. This is an ongoing process that drives the development and periodic revision of a plan based on information collected from the individuals in a person’s life.


Carolinas Home Care Agency, Inc. referral and linkage activities connects a recipient with medical, behavioral, social and other programs, services, and supports to address identified needs and achieve goals specified in the person centered plan. Referral and linkage activities include but are not limited to:

  1. Coordinated the delivery of services to reduce fragmentation of services and supports and maximize mutually agreed upon outcomes.
  2. Facilitating access to and connecting recipients to services and supports identified in the person centered plan.
  3. Making referrals to providers for needed services and scheduling appointment with the recipient.
  4. Assisting the recipient as he or she transitions through levels of care
  5. Facilitating communication and collaboration among all service providers and the recipient.
  6. Assisting the recipient in establishing and maintaining a medical home with a Community Care of North Carolina (CCNC) Physician or other primary care physician.


Monitoring/Follow-up of Clients

Monitoring and follow up includes activities and contracts that are necessary to ensure that the Person Centered Plan is effectively implemented and adequately addresses the needs of the recipient. Monitoring activities may involve the recipient, his or her supports, providers, and others involved in services/support deliver. Monitoring activities helps determine whether:

  1. Services are being provided in accordance with the recipient’s person centered plan
  2. Services in the Person Centered Plan are adequate and effective
  3. There are changes in the needs or status of the recipient and
The recipient is making progress toward his or her goals