(1) Targeted case management services include:
(a) comprehensive assessment and periodic reassessment of an eligible youth and the youth's family or caregivers to determine the need for any medical, educational, social, or other services. The assessment activities include the following:
(i) taking youth and the youth's family or caregivers history;
(ii) identifying the needs of the youth and the youth's family or caregivers, and completing related documentation; and
(iii) gathering necessary information from other sources, such as family members, medical providers, social workers, and educators to make a complete assessment of the eligible youth.
(b) development and periodic revision of a specific care plan based on the information collected through the assessment that includes the following:
(i) specific goals and actions to address the service needs of the youth and the youth's family or caregivers, including but not limited to medical, social, and educational needs;
(ii) the active participation of the eligible youth and the youth's family or caregivers in developing the goals and actions of the care plan; and
(iii) a course of action designed to respond to the assessed needs of the eligible youth and the youth's family or caregivers.
(c) referral and related activities, such as making referrals and scheduling appointments for the youth, helping the eligible youth and the youth's family or caregivers obtain needed services, helping to link the youth and the youth's family or caregivers with medical, social, and educational providers or other programs and services that provide needed services to address identified needs and achieve goals specified in the care plan; and
(d) monitoring and follow-up activities, including activities and contacts necessary to ensure that the care plan is effectively implemented and adequately addresses the needs of the eligible youth and the youth's family or caregivers. The monitoring and follow-up activities may be with the youth, family members or caregivers, service providers, or other entities or individuals and may be conducted as frequently as necessary, including at least one annual monitoring review to help determine whether the following conditions are met:
(i) services are being furnished in accordance with the youth's care plan;
(ii) services in the care plan are adequate to meet the needs of the youth and youth's family or caregivers; and
(iii) changes in the needs or status of the eligible youth have been accommodated. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.
(2) Targeted case management may include contacts with noneligible individuals who are directly related to the identification of the eligible youth's needs and care for the purpose of helping the youth access services, identifying needs and supports to assist the eligible youth in obtaining services, providing case managers with useful feedback, and alerting case managers to changes in the eligible youth's needs.