Standards for public agencies

2020 Edition

Case Management (PA-CM) 5: Intensive Case Management

Intensive case management services connect individuals and families to a coordinated, comprehensive array of services that meet their ongoing needs.
NA The agency does not provide Intensive Case Management Services.
2020 Edition

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Individuals and families who receive Case Management services access and use resources and supports that build on their strengths and meet their service needs.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Client contact procedures
  • Intensive case management caseload size requirements set by policy, regulation, or contract
  • Documentation of current caseload size per worker
  • Resume or formal agreement with psychiatrist or qualified medical personnel
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

Fundamental Practice

PA-CM 5.01

As needed, the agency directly provides, or formally arranges for, and coordinates:
  1. 24-hour crisis intervention;
  2. psychiatric services;
  3. housing services;
  4. medical and dental services;
  5. alcohol and other drug education and treatment;
  6. public assistance and income maintenance;
  7. family support services;
  8. vocational training and job placements; and
  9. transportation.

PA-CM 5.02

Case managers help individuals and families strengthen and manage the quality of their lives by:
  1. initiating change agent activities;
  2. teaching problem solving skills; and
  3. modeling productive behaviors.

Fundamental Practice

PA-CM 5.03

Caseload sizes range between 10 and 15 cases depending on the needs of individuals and families, the goals sought by the intervention, and the frequency of contact.

PA-CM 5.04

The agency makes direct contact with the individual or family at least four times per month.

Fundamental Practice

PA-CM 5.05

A psychiatrist or another qualified health practitioner with experience appropriate to the level and intensity of service and persons served, is responsible for the psychiatric aspects of the program.


The agency may use a consulting psychiatrist or community mental health center with which it has a formal agreement for psychiatric consultation.