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CHW 104: Service Skills, Case Management and Documentation
104.1 Care Coordination and Case Management
Intake, screening, need levels, wellness plans and closing a case
Your materials
Slides (PowerPoint) Handout (Word)
For instructors
Facilitator guide Printable pre and post tests Quiz (LMS import)
What you will learn
- Guide a client through consent, a short screen and a long intake
- Assign a low, medium or high need level using program guidance
- Build a wellness plan with goals the client chooses
- Set a contact schedule and close a case with care
Start here
Think about a time you asked for help. What made you want to go back, or not go back?
Lesson
The case management path
Every client in our program moves along the same path:
- Welcome and consent: Explain your role, what you will ask, and that the client can say no.
- Short screen first: Use the short social needs form to find the biggest needs fast.
- Long intake next: Go deeper on health, habits, stress and supports. Plan about one hour.
- Set the need level: Mark the client low, medium or high need and tell your supervisor.
- Make a wellness plan: Write goals the client picks, with small steps and helpers.
- Follow up and close: Check in on schedule, track progress, and close the case with care.
What a social needs screen asks about
| Need area | Example question topic |
|---|---|
| Living situation | Safe, steady place to live; worry about losing it |
| Food | Running out of food before there is money |
| Transportation | Missing care or work because of no ride |
| Utilities | Shutoff notices for gas, electric or water |
| Safety | Being hurt, threatened or put down at home |
| More areas | Money strain, work, support, school, mental health |
The federal screening tool at a glance
- 5 core need areas: housing, food, rides, utilities, safety
- 10 questions in the core part of the tool
- 11+ safety score that flags a safety need right away
Source: CMS AHC Screening Tool Guide
Low, medium and high need
| Level | What it can look like | What we do |
|---|---|---|
| Low | One need; client can follow through alone | Share resources, check in as scheduled |
| Medium | Several needs, or a health problem not managed | Navigate together, weekly contact, track referrals |
| High | Safety, housing loss or urgent health concern | Tell supervisor today, frequent contact, team plan |
A wellness plan the client owns
The wellness plan turns intake answers into action.
- Client picks goals: Ask what matters most to them now. Their goal may differ from yours, and that is okay.
- Small, clear steps: Write steps that can be counted and checked, like walking 10 minutes three days this week.
- Name the helpers: List people and places that can help: family, church, neighbors, clinic, programs.
- Review each contact: Check goals at every contact, celebrate progress, and change steps that are not working.
ACEs and resilience, with care
- What ACEs are: Adverse childhood experiences: possibly traumatic events from birth to age 17, like abuse, neglect or violence at home.
- Only with direction: Use ACEs and resilience tools only when your provider or supervisor directs it, and explain why.
- Client chooses: Clients can skip any question. Go slow, watch for distress, and have support ready, including 988.
- Strengths count too: Safe, stable, nurturing relationships protect people. Ask about the people who helped them grow.
Reading an intake upstream
- What we see: Mr. Coleman in Fairfax keeps missing diabetes visits. His short screen shows food and transportation needs.
- Why it happens (upstream): Grocery stores left the area, his bus trip takes over an hour, and his work hours were cut.
- What we can build on (assets): His church food pantry, a neighbor with a car, a nearby community garden, and the clinic CHW team.
Situation: the safety questions
Situation: During a phone intake, Ms. Rivera in Clark-Fulton answers the safety questions. Her answers show she is afraid of her partner. She whispers, then asks you not to tell anyone.
What do you do right now?
- Ask if she is safe to talk right now, or call later
- Thank her, stay calm, and do not judge or push
- Call 911 if she is in danger right now
- Follow the safety protocol and tell your supervisor today
Contact schedule and closing a case
- Weekly at the start: Contact each new client weekly until the team review sets the schedule.
- Log every contact: Note date, type (phone, video, visit), goals checked and referrals followed.
- Close when it is time: Goals met, client chooses to stop, moved away, or cannot be reached per protocol.
- Close with care: Review progress, celebrate wins, share resources, and say how to come back.
- Finish the file: Write a closing note and send it for supervisor review.
Study sheet
The big idea: Case management is a path we walk with the client: consent, screen, plan, follow up, and close with care.
Key points
- Consent comes first. Explain your role, the questions, the limits of privacy, and the right to say no.
- Start with the short social needs screen, then do the long intake, which takes about one hour.
- Need levels (low, medium, high) guide how often we reach out and who else we bring in.
- The wellness plan uses goals the client chooses, with small, checkable steps and named helpers.
- Use ACEs and resilience tools only at provider or supervisor direction, and let clients skip questions.
- Every new client gets weekly contact until the team review sets the schedule.
- Close cases with a review, a celebration of progress, and a clear way to come back.
Remember
- Five core screening areas: living situation, food, transportation, utilities, safety
- A safety score of 11 or more on the CMS tool flags a safety need
- Danger right now: 911. Mental health crisis: call or text 988
- Cuyahoga County child abuse hotline: 216-696-KIDS (216-696-5437), 24 hours
Ask yourself
- Which intake question would be hardest for me to ask, and how can I ask it with respect?
- How do I make sure the goals in a wellness plan belong to the client, not to me?
Vocabulary
| Word | What it means |
|---|---|
| Case management | Working with one client over time to find needs, set goals and connect to services. |
| Care coordination | Making sure a client's providers and services work together and share the right information. |
| Intake | The first meeting where we learn about a client's needs, health and supports. |
| Informed consent | A client's yes to services after we explain what we do, the limits, and their right to say no. |
| Screening | A short set of questions to find possible needs. It is not a diagnosis. |
| Health-related social needs | Needs like housing, food, rides, utilities and safety that affect a person's health. |
| Need level | Our program's rating of low, medium or high need, used to plan contact and support. |
| Wellness plan | A written plan of goals the client chooses, with small steps and helpers. |
| Adverse childhood experiences (ACEs) | Possibly traumatic events in childhood, ages 0 to 17, such as abuse, neglect or violence at home. |
| Resilience | The ability to adapt and recover, built by supportive people, skills and community. |
| Case closure | Ending regular services in a planned way, with a review and a path back. |
Real-life situations
The client who wants to skip the form
Mr. Walker in Hough says the long intake is too personal and he just wants help with his rent. He is behind two months.
What to do
- Thank him for being honest and respect his choice
- Start with his top need: help him contact rent help through 211 or your program list
- Explain why some questions help, and offer to finish the intake over a few visits
- Mark which questions he skipped and note his need level for your supervisor
Why: Clients can say no to any question. Meeting the urgent need first builds the trust that makes a full intake possible later.
The goal that is not yours
Ms. Green in Glenville has high blood pressure. You hoped she would pick a salt goal, but she wants to work on getting her grandson into a summer program.
What to do
- Write her goal in the wellness plan, in her words
- Ask how the summer program would help her family and her stress
- Ask if she would like to add a small health step later
- Check her goal at your next weekly contact
Why: People act on goals they choose. Reducing a caregiver's stress is real health work.
The client you cannot reach
You have called Mr. Ortiz in Lorain for three weeks with no answer. His phone mailbox is full.
What to do
- Try other contact methods he agreed to at intake, like text or a mailed letter
- Check with your supervisor before any change to his case
- Follow the program protocol for how many attempts to make
- If you close the case, send a letter saying how to come back
Why: Phones get shut off and lives get busy. A careful process keeps the door open and protects the client.
The child in the story
During intake in Slavic Village, Ms. Daniels says her boyfriend hit her 6-year-old last week and left a bruise.
What to do
- Stay calm and thank her for telling you
- Tell your supervisor right away and follow agency protocol and Ohio law
- Know the Cuyahoga County children services hotline: 216-696-KIDS (216-696-5437), open 24 hours
- If the child is in danger right now, call 911
Why: Suspected child abuse must be reported. Explaining privacy limits at consent helps clients understand this ahead of time.
Activity: Intake to wellness plan practice
About 30 minutes.
- Work in pairs. One person plays a client using a practice case card from the facilitator. Do not use a real person's story.
- The CHW explains consent, then asks the short screen questions and notes the answers.
- Together, choose a need level and write one sentence on why.
- The CHW helps the client write one wellness plan goal with two small steps and one helper.
- Switch roles, then post your practice wellness plan in the course discussion.
Post-test
Ten questions. You need 75% to pass, with one retake. Your result is saved in this browser.
Sources
- Ohio Administrative Code 4723-26-13, CHW training program curriculum
- Ohio Administrative Code 4723-26-10, Standards of safe care by the CHW
- CMS, Accountable Health Communities Health-Related Social Needs Screening Tool Guide
- CDC, About Adverse Childhood Experiences
- SAMHSA, In Crisis (988 Suicide and Crisis Lifeline)
- Cuyahoga County Division of Children and Family Services