Core Competencies
This program provides home and community-based services to help individuals live independently instead of in institutions.
What is CFC (Community First Choice)?
This is the first step in the case management process where the case manager reviews information before contacting the participant.
What is screening?
This process is not a one-time event but happens continuously during every interaction with the participant.
What is assessing (ongoing assessment/monitoring)?
This process involves turning assessment findings like risks, needs, and strengths into clear actions and services.
What is planning?
This type of visit allows case managers to directly observe the participant’s environment, physical condition, and overall well-being.
What is a face-to-face visit?
These two entities provide oversight and funding requirements for DDA and CFC programs at the state and federal levels.
What are MDH (Maryland Department of Health) and CMS (Centers for Medicare & Medicaid Services)?
This system contains demographic information, eligibility status, assessments, and service history used during screening.
What is LTSS (Long-Term Services and Supports)?
This approach requires case managers to evaluate the participant’s health, environment, supports, and services together rather than separately.
What is a whole-person (holistic) assessment?
This type of planning ensures the participant’s voice, goals, and preferences are reflected while balancing safety and compliance.
What is person-centered planning?
This core question should guide every evaluation to determine whether services are effective.
What is “Is this working?”
This step in the case management process focuses on identifying strengths, needs, risks, and preferences to guide service planning.
What is Assessment?
These four key areas must always be assessed during screening: health & safety, environmental, psychosocial, and this area related to providers and services.
What is service stability?
This type of visit must occur within 10 business days of assignment and includes domains such as medical, functional, and environmental factors.
What is a face-to-face assessment (initial visit)?
These goals are designed to be Specific, Measurable, Achievable, Relevant, and Time-bound to track progress effectively.
What are SMART goals?
This type of monitoring includes reviewing visit records, provider notes, and systems like ISAS to verify services are actually being delivered.
What is data-driven evaluation / using service verification data?
This principle states that family input is important, but does not override participant choice unless there is legal authority such as guardianship.
What is person-centered planning / participant autonomy?
This policy requires at least two outreach attempts per week and certified letters beginning on Day 14 when a participant cannot be reached.
What is the UTC (Unable to Contact) policy?
This concept requires case managers to look beyond single incidents and instead identify trends such as increasing missed services or worsening isolation.
What is pattern recognition in assessment?
This requirement ensures that every service in a plan is clearly tied to a need, includes frequency, and identifies who is responsible.
hat is accountability in planning / clearly defined services and responsibilities?
This evaluation principle requires case managers to identify trends such as repeated missed visits or increasing caregiver stress rather than focusing on single events.
What is trend/pattern analysis in monitoring?
A case manager documents “participant is fine, no issues” without including details on services, risks, or follow-up actions.
What is insufficient or non-defensible documentation?
A case manager completes screening but fails to identify missed services, housing instability, and increasing isolation because each issue was reviewed separately instead of together.
What is failure to identify patterns of risk / lack of holistic screening?
A case manager focuses on a participant’s request for a new TV while missing unpaid rent, utility shut-off risk, and food insecurity revealed by the caregiver.
What is failure to prioritize needs over wants / failure to identify critical risks?
A case manager copies assessment language into a plan without linking risks to services, defining next steps, or identifying responsible parties.
What is poor or non-defensible planning (failure to translate assessment into action)?
A case manager confirms services are in place but does not assess participant satisfaction, goal progress, or whether risks are decreasing.
What is failure to evaluate service effectiveness / monitoring without true evaluation?