Case Management
Horizon's case management services are provided to support individuals with a mental health illness, substance use disorder or intellectual and developmental disabilities. The goal of case management is to advocate on behalf of the client's needs and assist the individual to access activities, supports, and services identified in the Individual Service Plan (ISP). The result is the successful identification of dependable supports in the community that promotes long-term wellness, healthy self-reliance, continued growth, and meaningful connections in the community.
Our Case Managers:
- Understand that physical health and environmental stressors can affect a person’s overall well-being.
- Coordinate with local resources and organizations when necessary to address whole-person health consistent with a wrap-around care model.
- Strive to connect individuals and families to community resources, needed services, and monitor for satisfaction of services and support received.
- Continually monitor and assess for any additional areas of need and support.
Horizon recognizes that people with intellectual and/or developmental disabilities (ID/DD) can experience the highest quality of life when they have choice and control about their care and community participation. The role of the case manager is to support the inclusion of all people into their communities, starting at birth with parents and transitioning to adulthood. Horizon case managers listen and look for ways to ensure that clients served can create and maintain meaningful community connections, natural supports, meaningful work, and can live as independently as possible.
Criteria for Admission: The individual who meets criteria must demonstrate significant limits in intellectual and adaptive functioning that is evident between the ages of 6 and 22 years of age. In addition, the individual must be diagnosed with a documented developmental disability that lists level of severity and that the disability is chronic due to a mental and/or physical impairment and resulting in substantial functional limitations before 22 years of age.
Mental health case management can become extremely important when adults or children need multiple services as a part of their behavioral health treatment. A Horizon case manager can act as a single point of contact with health and social services, mobilizing needed resources and finding the best and most appropriate care for the client.
Criteria for Admission: For adults, there must be documentation of the presence of serious mental illness, as well as a need for case management supports. For children or adolescents there must be documentation of a serious emotional disturbance or a risk of serious emotional disturbance, as well as a need for case management supports.
Studies show that people with a substance use disorder have better treatment outcomes if their other physical and behavioral health issues are addressed at the same time. But finding and managing treatment can be overwhelming. Horizon’s Case Managers act as a single point of contact to help manage and advocate for clients who struggle with substance use addiction.
Criteria for Admission: There must be documentation of the presence of a substance related disorder which meets Diagnostic and Statistical Manual of Mental Disorders -5 criteria.
Virginia has three Waivers for people with intellectual/developmental disabilities which are assessed and managed by Community Services Boards (CSBs). They are:
1. Building Independence Waiver: Adults who are 18-years and older, who are able to live independently may be eligible for this waiver. People with this waiver usually own, lease, or control their own living arrangements, and they don’t need supports all the time.
2. Family and Individual Supports Waiver: Individuals who live with their family, friends, or in their own homes may be eligible for this waiver. Individuals with medical and/or behavioral needs both adult and child may be eligible for this waiver.
3. Community Living Waiver: Adults and children who require supports in their homes may be eligible for this waiver.
If you reside in the City of Lynchburg or the Counties of Amherst, Appomattox, Bedford or Campbell County you can contact Horizon Behavioral Health to determine eligibility. Horizon staff will work with you to determine eligibility individual established by the Department of Behavioral Health and Developmental Services (DBHDS). Everyone found eligible for waiver services is then added to a state wide waiver waitlist. It is important to note that not everyone who requests an ID/DD Waiver will be found eligible and even when found eligible there may be a wait for a waiver slot. When available slots come open, a Waiver Slot Committee, made up of community volunteers and Department of Behavioral Health and Disability Services staff, select recipients from the list of people who have the highest level of need to receive the open waiver slot. Individuals may be on the wait list for years dependent on level of need, as level need changes so does placement on the waiver wait list priority list.
For more information:
Navigating the DD waivers: my life my community
Commonwealth Coordinated Care Plus (CCC+) Waiver
This waiver is the former Elderly and/or Disabled Consumer Directed (EDCD) Waiver and the Assisted Technology (AT) Waivers. These waivers were combined into one singular waiver which is the Commonwealth Coordinated Care Plus (CCC+) Waiver.
Criteria for Admission:
adults 65+ with a medical or nursing need and
individuals less than 65 years with a disability and a medical or nursing need.
To request CCC Plus Waiver services, contact your local Virginia Department of Social Services (DSS) or local Virginia Department of Health (VDH).
High Fidelity Wraparound is a service that helps families when a child is at risk of needing residential placement or is in a residential placement and needs discharge planning due to emotional or behavioral issues. The goal may be to help maintain a youth in their home and/or transition him back to the community from a residential placement with appropriate natural and professional supports in place to meet the child’s needs.
Criteria for Admission: Children are referred to this service through the Family Assessment Planning Teams and funded through the Comprehensive Services Act (CSA).
Some of our clients need more intensive adult or child behavioral health treatment due to some form of vulnerability. It is a field-based service where the case manager brings the services to the client. The approach is based on the Trauma Recovery Model, a seven-stage model that matches intervention/support to presenting behaviors and to underlying needs. If someone meets the criteria set forth by the U.S. Department of Justice, they can qualify for enhanced case management.
Criteria for Admission: Per the U.S. Department of Justice Settlement Agreement with the Commonwealth of Virginia, a monthly face to face meeting is required with clients that: a) receive services from a provider with a Conditional or Provisional License, b) have more intensive behavioral or medical needs as defined by the Supports Intensity Scale (SIS), c) have an interruption of service greater than thirty days, d) encounter the crisis system for a serious crisis or, for multiple less serious crises, within a three month period, e) have transitioned from a Training Center within the previous twelve months, f) resides in a congregate setting of five or more individuals, or g) lives in a congregate setting of five or more individuals.
