HomeMy WebLinkAboutExhibit 3TEMPORARY CARE
STANDARDS OF CARE APPLYING TO TEMPORARY CARE FACILITIES
I. CORE FUNCTIONS OF TEMTORA.RY CARE FACILITIES:
• The Mission znd Purpose of temporary care facilities is to provide emergency Housing and care to
individuals in dire need. including, but not limited to, assessment- case management_ linkage and referral .
to supportive services and housing oppornutiries within the Continuum of Care and community -at -large.
• Core Functions:
Temporary care facilities shall provide the following core functions to their clients:
Erner:encv Rousing, inciuding clothing, meals, and initial health screening for
communicable diseases.
Comprebier4sive Assessrnen( of current social. health (including mental health and
substance use/abuse), and employtnentJeducation conditions.
• Development of -Individualized Continuum of Care Plans describing a client's
needs for supportive services. establishing a setvice1referral plan and outlining the
client's personal goals towards attaining residential, financial and personal stability and
self-sufficiency.
• Linkaae,(Rgfer•ral to internal and external supportive services including, but riot limited
:a, benefit proms, Ir.-patient or out -patient mental health or substance abuse
r eam ent or support groups, education/vocational opportunttics, )ob counseling, training
and placement, child care and legal services, and transportation.
• Ohtplacemerjt to appropriate housing opportunities in the Primary or Advanced Care
levels of the Continuum of Care, in the Dade County cornmcntry or in the local
affordable housing market.
11 GENERAL STANDARDS - PROGRAM ENVIRONMENT
A. RESIDENTS
• Homeless individuals and families saved by temporary cart facilities shall be accorded
dignity and respect:. A grievance procedure providing for fair nonce and hearing shall be•nadc
known and available to clients by which to seek redress in the event that a client has a grievance
regarding the operadon of the temporary rare facility or should a client believe that he or she has
been unfairly accused of a rule infraction, or in the event of a decision by the temporary care
provider to refuse or terminate services .to the client
• Temporary care facilities shall demonstrate sensitiviry to clients' pnrnary language and culrural
background.
• Clients have both pnviicges and responsibilities relating to their stay at the temporary care
facility which shall be set forth in a Res:dent/Client Agreement that each client must sign upon
admission to the temporary care faciiity.
B. SAFE EN IROti'7VLEN'T:
• All temporary care facilities shall establish and enforce house rules governing use of alcohol, illegal
use of controlled substances, fighting, violent and/or inappropriate behavior for the purpose of protecting
the health and safety of clients and staff.
C. TEMPORARY CARE FACILITY STAFF:
• Temporary care facility adminisc-ators shall ensure that facility staff have Lr e qualifications, proper
training and supervision necessary and appropriate to the job funcnont,$) with which such staff members
are entrusted. •
D. NON-DISCRIMLNATION IN THE PROVISION OF ROUSING AND SERVICES:
• There shall be no discnmination on the basis of race, color, gender, sexual orientation. disability,
religion, or national origin in the provision of emergency housing and services to clients by temporary
care providers. No religious practice or affiliation requirement shall be imposed upon clients or
prospective clients.
E. COORDINATION. COOPERATION AND INTEGRATION:
• Each Temporary Care Provider shall work closely and cooperatively %with the Dade County Homeless
Trust. the OAP Program and OAP Program Providers, all other Trust -funded providers as well as other
comtrtuniry-based service providers to homeless individuals and families.
ID. PROVISION OF EMERGENCY HOUSING:
A. HOUSING;
• Length of Stay: Length of stay shall be determined by the temporary care facility, c nsistent with the
Dade County Community Homeless Plan goals for emergency care - to encourage the client's atcaintaent
of long-term self-sufficiency through the optimal utilization of housing and services offered through the
Contmuum of Cares Primary and Advanced stages of care. Clients arc expected to reside at temporary
care facilities for a short period of time (i.e. seven (7) to sixty (60) days). Extension of a maximum
length of stay, set by the temporary care facility, shall be made on a case -by -case basis, predicated on the
client's demonstrated commitment to the goals established by the client with the assistance of ease
management in his or her individualized Continuum of Care Plan. Violations of temporary care facilities
house rules may be grounds for terminating a client's length of stay and/or privilege of re -admission.
• Separate Sleeping Quarters and Personal Hygiene Facilities: Separate sleeping quarters and
personal hygiene facilities shall be maintained for (a) single male adults; (b) single female adults and (c)
families.
• Quality of Housing: Temporary care facilities shall maintain safe, clearer and sanitary conditions and
opportunity to safekecp papers, documents and valuables. Beds, pillows and bed coverings (e.g. sheets
and blankets) shall be ciean and sanitary (e.g. free of infestation).
• Personal Hygiene Facilities: Personal hygiene facilities shall be made available to each client. Such
personal hygiene facilities shall be kept clean and sanitary and maintained in operable working condition
at all times. subject to periodic temporary interruptions due to maintenance or repair.
• Resident Participation in General Housekeeping: Clients may be reauircd to participate in the
general housekeeping of the temporary care facility.
B. MEA.L STANDARDS:
• Provision of Meals: Clients shall be provided a minimum of two meals a day, one of which must be a
hot meal.
• Meal Standard: All meals served shall be nutritionally sound and balanced in compliance with
standards and/or regulations adopted and/or issued by the local pubiic authority responsible for the
regulation of facilities which serve meals at residential facilities.
C. CLOTHING STANDARDS:
• Provision of CIotliing: Temporary care facilities shall assist clients in obtaining at least two sets of
appropriate clothing (both under and outerwear) and shoes. Appropriate clothing in the instance of
underwear and sods shall mean new or previously unused items.
D. HEALTH SCR.EENTNGS:
• Immediate Health Screening: To reduce risk of harm to other clients and staff. temporary cart
facilities shall arrange for health screenings for communicable. air -borne diseases. such as tuberculosis.
within thirrv-six (36) hours of the client's entry into the facility. Clients deterrnmed to pose a direct
treat to the health of others shall be quarantined and referred for appropriate medical treatment
• Fuli Medical Assessment and Evaluation: Temporary care facilities shall arrange far a full medical
assessment and evaluation (i.e. complete physical) for each client within seventy-two (72) hours of the
client's entry into the facility.
FACILITIES STANDARDS AND LICENSING/CERTIFICATION:
• Temporary Care Facilities in General: Temporary care facilities shall comply with all local and
state ordinances. regulations or laws governing residential facilities and secure necessary licensing as
may be required under such local or state law.
• Food Preparation and/or Dining Facilities: Food preparation and/or dining facilities located at
temporary care facilities must comply with all local and state ordinances. reeulations and laws governing
facilities which serve meals to the public ui a residential facility or otherwise. Temporary care facilities
must secure necessary liccnsine or certification as may be required by the local public authority
responsible for the regulation of facilities which serve meals to the public.
• Environmental/Structural Controls and Procedures to Prevent/Control Spread of
Communicable Diseases: Temporary care facilities shall -comply with all locai and state ordinances,
regulations and laws eoverrune the prevention and/or control of the spread of communicable, air -borne
diseases within residential facilities which may include the implementation of structural or
environmental me sure:, and auarantinuta, notification and health screenine procedures.
IV- TEMPORARY CARE CASE MANAGEMENT:
A. CASE MANAGEMENT SERVICES IN GENERAL:
• The Mission and Purpose of temporary care facilities is emergency housing and care. The case
management funcion at Temporary cart facilities shall be one of assessment., advo-_acY and 1Lfl$aec a_s
opposed to treatment due to the short stay of clients. Assisting the client in obtaining needed housing and
scrvicrs shall be the essential function of the temporary care facility.
• The Primary Purpose of Case Management Services is to integrate various•internal and external
service components into a coherent constellation of services tailored to meet the unique needs of
individuals Case Management shall be concerned with service coordination and problem solving in an
attempt to insure appropriate service provision and continuity.
• Partnerships: The temporary care facility shall develop partnerships with government_ not -for -profit
and community -based agencies or organizations or programs to coordinate and provide services to Its
ciients.
• Case Managers: The case manager shall be responsible for producing a comprehensive assessment of
the client's current social. health (including mental health and substance LISC abusc) and
education/employment conditions and nods. The case manager shall play a major role in assisting the
resident in the development and implementation of a Continuum of Care Plan which will enable the
client to succe :s;ully achieve his or nor personal goals and objectives by addressing unmet needs.
• Client Rapport: Deveioprnent of a rapport between the client and his or he: cast manager,
establishing mist and famtiiartrv, is deemed integral to establishing an effective Case management
service plan and a realistic. client-deveiooea Continuum of Care Plan.
• Scope of Case Management Services: The scope of case management services provided shall be
client directed.
13. CORE CASE MANAGEMENT FUNCTIONS
• Core Functions of a temporary cart facilities case management program shall be:
Assessment - a thorough evaluation detailing the client's current and potential strengths,
weaknesses, service needs and approprate resources to meet the service needs.
flan n in* - the development of a holistic service plan with each client, containing service goals
and appropriatc timeliness.
Linkar/I3rokt_rage - the process of referring or transfemng clients to all required internal and
external services.
Monitorinz - the continuous evaluation of the client's progress, leading to reassessment and
development of new service plans, linkages, or outer dispositions as indicated.
• Areas of Case Management Intervention should include but are not limited to:
• Service Planning.
• Assistance in obtaining food and clothing and trasisaortanon.
• Referrals for in- or out -patient mental health services, substance abuse treatment, and medical
services.
• Assistance in obtaining benefits.
• Referrals to self-sufficiency related program such as adult education- vocational training, job
counseling, training and permanent placement services, child care and legal services and
transportation.
• A.ssistancc and referral to obtain appropriate housing placement in the Primary or Advanced
Care ieveis of the Continuum of Care. in the Dade County community or in the local affordable
housing market.
C. MULTI-DISCIPLLti'AR1' TEAM CONCEPT:
• Recommendation: It is recommended that temporary care providers develop a multi -disciplinary
approach towards providing care to the client to ensure an holistic response to the client's needs.
Temporary care providers are encouraged to develop multi -disciplinary care tea ins, comprised of the
client's case manager, a health care worker caring for the client. andior government or community
providers dire tiv sernng the citenu t.h.at wouid meet to renew client progress. make recommendations
and ensure successful referral to additional services and resources. Such approach ensures effective,
comprehensive service provision as weil as continuity of care as the client is placed with other housing
programs within the Connnuum or in the cornmuntrv.
COMPREHENSIVE ASSESSMENT:
• Comprehensive Assessment Precedes Case Management Services: Cast management services
shall be preccaed by a comprehensive assessment of the client's current social. health (including mental
health and substance useiabtise) and educauon/employment conditions. Screening for emotional
disorders and dysfunctions, including substance abuse, and for other serious mental health impediments
to independence, shall be performed by, or under the supervision of, qualified mental health or substance
abuse professionals.•
• Client Rapport: Development of a rapport between the client and facility staff responsible for the
assessment function, cstablishine a-ust and familiarity, is deemed integral to performing a thorough and
accurate comprehensive assessment of the client's needs and to establishing an et%cnve case
management service plan and a realistic, client -developed Continuum of Care Plan.
• Comprehensive Assessment within 7: Hours: A comprehensive assessment of the client's current
social, health and educatiorvernpioyment conditions shall commence within seventy-two (72) hours of
admission of the client to the temporary care facility.
• Contents of Comprehensive Assessment: The comprehensive assessment shall include treatment and
referral recommendations and wiil form the basis for the client's individualircd Continuum of Care Plan
and referral services provided to the client. The comprehensive assessment shall be comprised of
information gathered by the OA.P Program. by the Dade County Hameiess Trust. at intake, through client
interviews and through medical and refer ai information.
V1. INDIVLDUALIZED CONTINUUM OF CARE PLAN:
• Client -Developed Continuum of Care Plan - Timeliness: Clients shall bc assisted in mitiatine an
individualized Continuum of Care Plan within twenty-four (24) hours of the compaction of their
comprehensive assessment of their current social, health and education/employment conditions and
needs.
• Client Contract: The Cantu -mum of Care Plan is an individualized contract based upon the
participant's current state, capabilities and personal goals. The Continuum of Care Plan shall describe
the participant's needs for supportive scsviccs and outline the steps that the participant must take in order
to begin the personal proces towards residential and financial stability and self-s-ufficiency, The client's
signature on the Conanuurn of Care Plan signifies his or her commitment to obtaining residential,
fsnanciai and personal s~.abiiity and self-sufficiency.
• Basis of Individualized Continuum of Care Plan: The individualized Continuum of Care Plan shall
be based on the comprehensive assessment of client's conditions and nerds, as well as case management
recommendations. and the ciicnt's personal goals and objectives. Goals and/or services sought by the
client should be consistent with those articulated by the client during initial engagement and assessment
by the Trust -coordinated Outreach. Assessment and Placement Program.
• Potential Needs to be Reflected in Client's Goals and Objectives: The individualized Continuum of
Care Plan shouid address the following goals and objectives that respond to the following potential
needs: health (physical and mental heaitlt including substance abuse), education, vocational skills and
employability, benefits and/or benefits. housing, child care and legal services. as well as
;amiiy/interpersonai issues and sptrtruaiity.
• Establish Realistic Goa1s: Unreaiistrc goals should bc avoided to prevent discouragement with the
rehabilitation process. Conversely, too simplistic goals should be discouraged to prevent loss of interest
by the client due to the existence of too few challenges. The choices made by the client with the
assistance of his or her case manager should be realisnc and within the client's range of skills, abilities
and present circumstances.
• Weekly Monitoring of Client Progress: The paricipant's progress in meeting goals set forth in the
Continuum of Care Plan should be monitored on a weekly basis through weekly meetings with the
client's cast manaeer.
• Flexibility and Adjustment: Continuum of Care Plans are intended to be individualized, flexible
service pians facilitating steady movement toward independent living at a pace suited to each
participant's circumstances and needs. The Conunuum of Care Plan must be adjusted to reflect progress
or identified areas where additional attention is needed either by the client's own efforts or through the
provision of additional services and/or resources.
VII. CLIENT CONFIDENTIALITY AND SHARING OF INFORMATION:
• Client Expectation of Privacy: Temporary care facilities shall comply with all federal and state laws
and tee -Wm -ions governing the confidentiality of information regarding AIDS/HT\ status and medical.
substance abuse or mental health history, referral or treatment. Clients may expect a reasonable decree
of privacy with regard to iniorrnauon not otherwise protected from disclosure ov fcacrai or state laws
and regulations that is shared with the temporary care facility staff members.
• Personal Mail and Telephone Calls: Temporary care 'facilities shall respect the privacy of a client's
personal mail and telephone calls.
• Exceptions to Client Confidentiality: Client information may be subject to disclosure as provided by
law including investigation by law enforcement: probation offices, and HRS protective services related
to minors or the elderly, subject to any limitations on disclosure set forth in state or federal law,
including those laws protec^.ng the coniideritiaiity of information regarding AIDS/HIV status and
medical. substance abuse or mental health history, referral or trcatment-
• Sharing of Client Information: Sharing of client information with other provider to whom the client
may be referred is necessary to ensure effective provision of services, continuity in care, :rid efficient
use of Continuum resources. The necessity of sharing information with other providers shall be
explained to the client. Client information shall only be shared upon the client's wnrten consent_
Vff OUTPLACEMENT SERVICES:
• Urgency: TT rn:ss:on and ourPose of temporary care facilities is to provide emergency housing and
care to individuals in dire need. In keeping with this purpose, the temporary care facility should make
every effort to secure _n approonate housing placement for a client as soon as possible. Case manager
snouid be thintar.g of aonrow:ate out-oiacernent by the r.rne the Continuum of C.;rc Plan is signed and
implemented.
• Provider Relationships: Temporary care facility case managers arc expecte-d to develop strong
working relataonsnips with pnmary and/or advanced care case managers to ensure an effective planning
process and smooth transition between housing programs.
• Effective Planning Process to Ensure Smooth Transition: The planning process should strive to
ensure that minimal disruption occurs during the transition from one provider to another. The planning
process is intended to ensure that services provided to the client at or through referral by the temporary
care faciiiry are maintained and that the provision of additional services are arranged for the client prior
to transfer, consistent with the client's individualized Connnuum of Care Plan.
• Outplacement Packet: The necessity to cooperate with both the Temporary Care Provider and the
provider with whom the client has been placed in order to ensure effective service provision and
continuity of care shall be explained to the client. Upon the written consent of the client, an
outplacement packet shall be prepared for the provider with whom the client has been placed. The
outplacement packet shall contain the client's comprehensive assessment, Continuum of Care Plan and
referral history and nnrrc for the nuroose of rnsiirinr continuity in servirr nrnvtcinn anti in the client's
PRIMARY CARE
STANDARDS OF CARE APPLYING TO PRIMARY CARE FACILITIES
I. CORE FUNCTIONS OF PRIMARY CARE FACILITIES:
• The Mission and Purpose of primary care facilities is to provide housing and supportive services to
special need homeless populations comprised of persons with a history of mental illness tar dehabilitating
mental health conditions, substance abuse, victims of domestic violence, HIV infection or AIDS. as well
as homeless individuals and families in order to assist such persons in the transition from homelessness
to independent living or to permanent supported housing, as the case may be.
• Core Functions:
Primary care facilities shall provide the following care functions to their clients:
Housing including clothing, meals. and initial health screening for
communicable diseases.
•
•
Comprehensive/Revised Assessment of current social, health (including mental health
and substance useiabuse j, and employment/education conditions and
Development/Revision of individualized C_orttinuum of Care Plans describing a
client's needs for supportive services. establishing a serviceireferral plan and outlining
the client's personal goals towards attaining residential. financial and personal stability
and self-sufficiency.
Mental Health/,huh lance Buse Treatment or Rehabilitative Support through an -
site treatment for menus illness or denabiiitattng mental health conditions. including
substance abuse. or referral to out -patient treatment for same. andior on and off -site
support groups andior activities.
Linkage/Referral to internal and external supportive services including, but not limited
to, benefit programs, primary health case. education/vocational opportunities, job
counseling, training and placement, child care and legal services, and transportation.
Outplacement to appropriate housing opportunities in the Advanced Care
level of the Continuum of Care, in the Dade County community or in the local
affordable housing market and Follow-itn Case Management Services for at least
ninety days following ournlacement.
II. GENERAL STANDARDS - PROGRAM ENVIRONMENT
A. RESIDENTS
• Homeless individuals and families served by primary care facilities shall be accorded dignity
and respect A grievance procedure providing for fair notice and hearing shall be made lztowzt
and available to clients by which to seek redress in the event that a client has a grievance
regarding the operation of the primary care facility or should a client believe that he or she has
been unfairly accused of a rule infraction. or in the event of a decision by thc primary care
provider to ren.tse or terminate services to the client.
• Primary care facilities shall demonstrate sensitivity to clients' primary language and cultural
background.
• Clients have both privileges and responsibilities relating to their stay at the primary cart
facility which shall be set forth in a Resident/Client Agreement that each client must sign upon
admission to the primary care facility. •
B. SAFE ENVIRONMENT:
• All primary care facilities shall establish and enforce house rules governing use of alcohol, illegal use
of controlled substances, fighting, violent and/or inappropriate behavior for the purpose of protecting the
health and safety of clients and staff.
C. PRIMARY CARE FACILITY' STAFF:
• Primary care facility administrators shall ensure that facility staff have the auaiifications, licensing,
proper training and supervision nec:ssary and appropriate to the job functions) with which such staff
members arc cncusted.
D. NON-DISCRIMINATION IN THE PROVISION OF HOUSING AND SERVICES:
• There shall be no discrimination on the basis of race, color, gender, sexual orientation, disability,
religion. or national origin in the provision of housing and services to clients by pnmary care providers.
No religious practice or affiliation requirement shall be imposed upon clients or prospective clients.
E. COORDINATION, COOPERATION AND INTEGRATION:
• Each Primary Care Provider shall work closely and cooperatively with thc Dade County Homeless
Trust, the OAP Program and OAP Program Providers, all other Trust -funded providers as well as other
community -based service providers to homeless individuals and families.
LQ. PROVISION OF HOUSING:
A. HOUSENG:
• Length of Stay; Re-cognthng the existing scarcity of resources, the Dade County Community
Homeless Plan sets forth as guidance a length of stay of six (6) to nine (9) months in primary care
facilities (transitional housing). Regulations governing homeless programs funded by the U.S.
Department of Housing and Urban Development (U-S. HUD) provide for lengths of stay of up to twenty-
four (24) months to transitional housing. Inconsistencies in lengths of stay for various housing types. if
any, between the Dade County Community Homeless Plan and U.S. HUD guidelines are not intentional
substantive deviations from U.S. HUD guidelines, but rather reflect local funding allocations for various
lengths of stay in light of current available resources.
Length of stay shall be determined by the primary care facility, consistent with the Dade County
• Community Homeiess Plan goals for primary care - to encourage the client's attainment of long-term
self-sufficiency through the optimal utiiizaaon of treatment opportunities and/or supportive services
provided in the pnrnary care level. Maximum residency at primary care facilities is a period of six (6)
months. Extension of a maximum length of stay is subject to the review and approval by the Dade
County Homeiess Trust and shall be made on a case -by -case basis, predicated on the client's
Individualized Continuum of Care Plan and demonstrated commitment to his or her trestrrtent plan
and/or the goals established by the c'tient in his or her individualized Continuum of Care Plan.
Violations of pnmary care facilities house rules may be grounds for terminating a client's length of stay
and/or pnviiegc of re -admission. consistent with all locai and state ordinances. laws or regulations
governing tenancy, if and when applicable.
• Housing Placement Options: Housing placement options offered to the client shalt be consistent
with the client's Individualized Continuum of Carc Plan.
• Residential Facilities - Separate Sleeping Quarters and Personal Hygiene Facilities: Housing
Quarters offered to the client shall be consistent with the client's Individualized Continuum of Care Plan.
In the case of residential facilities that are not single sex facilities. separate sleeping quarters and
personal hygiene facilities shall be maintained for (a) single male adults; (b) single female adults and (c)
families:
• Quality of Housing: Primary care facilities shall maintain safe. clean and sanitary conditions and shall
provide ciicnts the opportunity to safekecp papers, documents and valuables. Beds, pillows and bed
coverings (c.g. sheets and blankets) shall be ciean and sanitary (e.g. free of infestation).
• Personal Hygiene Facilities: Personal hygiene facilities shall be made available to each client- Such
personal hygiene facilities shall be kept clean and sanitary and rnatntained in operable working condition
at all times, subject to penoaic temporary interruptions due to maintenance or repair.
• Resident Participation in General Iiousekeeping: Clients may be required to participate in the
general housekeeping of the primary care facility.
B. MEAL STANDARDS:
• Provision of Meals: Clients shall be provided a minimum of two meals a day, one of v{tich must be a
• Meal Standard: All meals served shall be nutritionally Su....� ,,
. , lanced in compliance for standards and/or regulations adopted and/or issued by the local �;..tt7lic ;11�,�
regulation of facilities which serve meai.s at residential facilities.
C CLOTHING STANDARDS:
• Provision of Clothing: Primary care facilities shall assist clients in obtaining at least two sets of
appropnate clothing (both under and outerwear) and shoes. Appropriate clothing in the instance of
underwear and socks shall mean new or previously unused items.
• Donated Clothing: Donated clothing must be washed/sanitized prior to dist:i ution to clients.
D. HEALTH SCREE OENGS:
• Immediate Health Screening: To reduce risk of Harm to other clients
and staff,
h as pnm caris. facilities
shall arrange for health screenings for communicable, air -borne diseases.
n
thirty-six (36) hours of the client's entry into the facility. Clients determined to pose a direct threat to the
health of others shall be aua.taritined and referred for appropriate medical treatment_
• Full Medical Assessment and Evaluation: in the absence of -documentation that a client has undergone a complete physical within the previous six months, primary care facilities shall arrange for a
full medical assessment and evaluation i i.e. complete physical) for each client within seventy-two (72)
hours of the client's entry into the facility.
E. FACILITIES STANDARDS AND LICENSING/CERTIFICATION:
• Primary Care Facilities in General: Primary care facilities shall comply With all local and state
ordinances, laws or regulations governing residential facilities arrdior housing conditions and secure
necessary licensing as may be rccuirea under such local or state law. Primary care facilities shalt also
comply with all local and state ordinances, laws or regulations governing providers of substance abuse or
mental health treatment and related services.
• Food Preparation and/or Dining Facilities: Food preparation and/or dining facilities located at
primary care facilities must comply with all local and state ordinances, regulations and laws governing
facilities which serve meals to the public in a residential facility or otherwise. Primary care facilities
must secure necessary licensing or ccriificanon as may be required by the local public authority
responsible for the regulation of facilities which serve meals to the public.
• Environmental/Structural Controls and Procedures to Prevent/Control Spread of
Communicable Diseases: Pnmary care facilities shall comply with all local and state ordinances.
regulations and laws governing the prevention and/or control of the spread of communicable, air -borne
diseases within residential facilities which may include the implementation of structural or
environmental measures and quarantining, notification and health screening procedures.
R'. PROVISION OF MENTAL HEALTH AND/OR SUBSTANCE ABUSE TREATMENT:
• Compliance with State Licensing Rules and Regulations: Primary Care prorrts that provide
treatment for chemical dependence/abuse and/or mental illness shall comply with state iicenstng rules
and regulations as follows:
• Chemical Dependency/Abuse Treatment Providers shall meet with standards and
regulations contained in Amended Rule 10E-16 and shall obtain a license to operate the program
according to definitions and classifications more specifically contained in Se non !0E-16.009 .
FAC. ~
• Providers Serving the Mentally Ill shall comply with Rule l0E-4.016 and shall obtain a
license to operate the specific program or "level of care" as classified in Section 10E-4.016(4)
F.A.C.
• Providers Serving the Dually Diagnosed: Where the primary care provider aims to serve the
dually diaenosed popuianon. the disability that is primary addressed shall determine whether a
substance abuse or mental health treatment license is the appropriate choice.
V. PRIMARY CARE CASE MANAGEMENT:
A. CASE MANAGEMENT SERVICES IN GENERAL:
• The Mission aad Purpose of primary care facilities is to provide housing and suoporitve services to
special need populations comprised of pawns with a history of mental illness or dchabiiitating mental
health conditions, including substance abuse, victims of domestic violence. HIV infection or AIDS. as
well as homeless families in order to assist such persons in the transition from homciessncss to
independent living or to permanent supported housing, as the case may be.
• The Primary Purpose of Case Management Services is to integrate various internal and external
service components into a coherent constellation of services tailored to meet the unique needs of
individuals. Case Management shall be concerned with service coordination and problem solving in an
attempt to insure appropriate service provision and continuity.
• Partnerships: The prirnary care faciiiry shall deveiop partnerships with government, not -for -profit and
communiry-based agencies or organizations or programs to coordinate and provide services to its clients.
• Case Managers: The case manager shall be responsible for producing a comprehensive or revised
assessment, as the case may be, of the client's current social, health (including mental health and
substance usuabuse) and educatiorvempioyrnent conditions and needs. The case manager shall play a
major role in assisting the resident in the development, or revision. and implementation of a Continuum
of Care Plan which will enable the client to successfully achievertis or her personal goals and objectives
by addressing unmet needs.
• Client Rapport: Development of a rapport between the client and his or her case manager,
establishing rust ana farniiiariry, is deemed integral to establishing an effective case management
service plan and a realistic. client -developed Continuum of Care Plan.
• Scope of Case Management Services: ine scope of case man.aeement services provided shall be
client directed.
B. CORE CASE MANAGEMENT FUNCTIONS
• Core Functions of a primary care facilities case management program shouid bc:
Assessment - a thorough evaluation detailing the client's current and potential strengths,
weaknesses, service needs and appropriate resources to meet the service needs.
j'tannina - the development of a holistic service plan with each client, containing service goats
and appropnate timeliness.
Linizape/Brokerape - the process of referring or transferring clients to all required internal and
external services_
Mon itorin- - the continuous evaluation of the client's progress. leading to reassessment and
development of new service pians, linkages, or other dispositions as indicated.
• Areas of Case Management intervention should include but are not limited to:
• Service Planning.
• Assistance in obtaining food and clothing and transportation-
• Referrals for in- or out -patient mental health services, substance abuse treatment, and medical
services.
• Assistance in obtaining benefits.
• Provision and/or referrals to self-sufficiency related programs and services such as adult
education, vocational training, job counseling, training and permanent placement services, child
care and legal services and transportation.
• Assistance and referral to obtain appropriate housing placement in the Advanced Care level of
the Continuum of Care, in the Dade County com.rnuniry or in the local affordable housing
market.
MULTI-DISCIPLLNARY TEAM CONCEPT:
• Recommendation: It is recornmended that primary care providers develop a multi -disciplinary
approach towards providing care tc the client to ensure an holistic response to the client's needs.
Primary care providers arc encouraged to develop multitiiscipiinasy care teams, comprised of the
client's case manager, a health care worker caring for the client. and/or government or community
providers directly serving the client that would meet to review client progress, make recommendations
and ensure successful referral to additional services and resources. Such approach ensures effective,
comprehensive service provision as well as continuiry of care as the ciient is piacea with other housing
prograth.s within the Continuum or in the community.
vI. COMPRESENSIVE ASSESSMENT AND INDIVIDUALMFD CONTINUUM OF CARE
PLAN:
A. COMPREHENSIVE ASSESSMENT:
• Comprehensive Assessment Precedes Case Management Services: Case managerncnt services
shall be preceded by a comprehensive assessment of the client's cta'rrrtt social, health (including mental
health and substance use/abuse) and education/employment conditions. Screening for emotional
disorders and dysfunctions, including substance abuse, and for other serious mental health impediments
to independence, shall be performed by, or under the super ision of, qualified mental health or substance
abuse professionals. The comprehensive assessment of the client's social, health and
education/employment needs shall commence within seventy-two (72) hours of admission of the client to
the Primary care facility.
In the event that a ciicnt was referred by a temporary care provider or another primary care provider, the
client's comprehensive assessment documentation prepared by the referral provider shall be reviewed
and revised by the current primary care provider. Such review and revision shall commence within
sevenry-rwo (72) hours of admission of the client to the primary care facility.
• Client Rapport: Development of a rapport between the client and facility staff responsible for the
assessment function, establishing trust and familiarity, is deemed integral to performing a thorough and
accurate comprehensive assessment or revised assessment, as the case may be. of the client's needs and
to establishing an effective cast management service plan and a realisuc, client -developed Continuum of
Care Flan.
• Contents of Comprehensive Assessment: The comprehensive assessment shall include treatment and
referral recommendations and will form the basis for the client's individualized Continuum of Care Platt
and referral services provided to the ciicnt_ The comprehensive assessment shall be comprised of
information gathered by the OAP Program. by the Dade County Homeless Trust at intake, through client
interviews and t-irouen medical and referral information
B. INDIVLDUALLZED CONTINUUM OF CARE PLAN:
• Client -Developed Continuum of Care Plan - Timeliness: Clients shall be assisted in initiating an
individualized Continuum of Care Plan within twenty-four (24) hours of the completion of their
comprehensive assessment of their current social, health and education/employment conditions and
needs.
In the event that a client deveioaed a Continuum of Care Plan while in the care of another provider, the
primary care provider shall incorporate the client's Continuum of Care Plan into the primary care
provider's service plan for the client, subject to revision by the client and his or her primary care case
manager.
• Client Contract: The Continuum of Care Plan is an individualized contract based upon the
participant's current state, capabilities and personal goals. The Continuum of Care Plan shall describe
the participant's needs for supportive services and outline the steps that the participant must take in order
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• Basis of Individualized Continuum of Care Plan: The individualized Continuum of Care Plan shall
be based on the comprehensive assessment of client's conditions and needs. as well as case management
recommendations, and the client's personal goals and objectives. Goals and/or scrim= sought by the
client should be consistent with those articulated by the client during initial engagernent and assessment
by the Trust -coordinated Outreach.. Assessment and Placement Program or while in the care of another
provider.
• Potential Needs to be Reflected in Client's Goals and Objectives: The individualized Continuum of
Care Plan should address the following goals and objectives that respond to the following potential
needs: health (physical and mental health including substance abuse), education, vocational skills and'
employability, benefits and/or benefits, housing, child care and legal services, as well as
family/interpersonal issues and spirituality.
• Establish Realistic Goals: Unrealistic goals should be avoided to prevent discouragement with the
rehabilitation process_ Conversely, zoo simplistic goals should be discouraged to prevent loss of interest
by the client due to the existence of too few challenges. The choices made by the client with the
assistance of his or her case manager should be realistic and within the client's range of sills, abilities
and present circumstances.
• Weekly Monitoring of Client Progress: The participant's progress in meeting goals set forth in the
Continuum of Care Plan should be monitored on a weekly basis through weekly meetings with the
client's case manager.
• Flexibility and Adjustment: Continuum of Care Plans are intended to be individualized, flexible
service plans faciiitattne steady movement toward independent living at a pact suited to each
participant's circumstances and needs. The Continuum of Care Plan must be adjusted to reflect progress
or identified areas where additional attention is needed either by the client's own efforts or through the
provision of additional services and/or resources.
VIII. OUTPLACEMENT SERVICES:
• Housing Options: The mission and purpose of primary care facilities is to provide housing and
supportive and/or treatment/rehabilitative services necessary to assist the client in the t;-ansirion from
homelessness to independent 'living or permanent supported housing, as applicable. In keeping with this
purpose, the primary care facility should make every effort to assist the client in securing an appropriate
housing placement as soon as reasonable and appropriate for the client.
• Provider Relationships: Primary cart facility case managers arc expected to develop strong working
relationships with primary and/or advanced care case managers to 'ensure an effective planning process
and smooth transition bcrween housing programs.
• Effective Planning Process to Ensure Smooth Transition: The planting process should strive to
ensure that minimal disruption occurs during the transition from one provider to another. The planning
process is intended to ensure that services provided to the client at or through referral by the primary care
facility are maintained and that the provision of additional services are arranged for the client prior to
transfer, consistent with the client's individualized Continuum of Care Plan.
• Outplacement Packet: The necessity to cooperate with both the Primary Care Provider and the
provider with whom the client has been placed in order to ensure effective service provision and
continuity of care shall be explained to the client. Upon the written consent of the client, an
outplacement packet shalt be prepared for the provider with whom the client has been placed. The
outplacement packet shall contain the client's comprehensive assessment. Continuum of Care Plan and
referral history and notes for the purpose of ensuring continuity in service provision and in the client's
commitment to his or her goals and objectives.
• Follow -Up Case Managetnent Services: The primary care provider responsible for referral and
placement of a client with an advanced care provider or in permanent housing available to the client in
the Dade,Counry community shall provide follow-up case management services to the client for at least
ninety days following the date of outplacement_