The definitions of case management services for children with special health care needs are as follows:

(1) "Assessment" means an evaluation of a child's physical, medical, nutritional, psychological, social, developmental, and educational status in the context of the child's caretakers to determine if the child meets the "at risk" criteria stated in ARM 37.86.3902 or if the child has diagnosed special health care needs, and to document the child's needs for resources and services.

(2) "Case plan" means a written, individualized, family-centered, culturally competent and coordinated case management service plan reflecting a child's needs and strengths. The plan provides goals of intervention, objectives, activities in context of the child's caregivers, and the resources and services available to meet the child's needs in a coordinated and integrated fashion.

(3) "Care coordination and referral" means assisting a child and child's caregivers to access resources and services, including children's special health services, specialty clinics, other needed services, and to establish and maintain eligibility for services other than medicaid. For those children for whom the developmental disabilities family education and support services program (DDFESS) retains lead status, care coordination activities are determined at the community level.

(4) "Developmental disabilities family education and support services (DDFESS) " means the developmental disabilities family education and support services program comprised of the federally authorized and funded Part H services, state funded family education and support services.

(5) "Monitoring" means regular contacts through ongoing home visitation and other means to assure appropriateness of services provided to the child and the child's caregivers, to identify and address concerns which may create barriers to services, and to assure the receipt of services as indicated in the case plan. Health and medical services for children served by DDFESS may be monitored by the children with special health care needs. Program monitoring functions include:

(a) utilizing information obtained from assessments of the child/family's needs and status; and

(b) modifying the case management service plan as needed in coordination with all involved providers in order to promote positive outcomes for a child and the child's caregivers.