Targeted Case Management Services: 
Intensive Care Coordination
Intensive Care Coordination (ICC) is a service that facilitates care planning and 
coordination of services for MassHealth youth, with serious emotional disturbance (SED), 
under the age of 21, and enrolled in MassHealth Standard or CommonHealth.  Care 
planning is driven by the needs of the youth and developed through a Wraparound planning 
process consistent with Systems of Care philosophy.

 Intensive Care Coordination (ICC) provides a single point of accountability for ensuring that 
medically necessary services are accessed, coordinated, and delivered in a strength-based, 
individualized, family/youth-driven, and ethnically, culturally, and linguistically relevant 
manner.  Services and supports, which are guided by the needs of the youth, are developed 
through a Wraparound planning process consistent with Systems of Care philosophy that 
results in an individualized and flexible plan of care for the youth and family.  ICC is designed 
to facilitate a collaborative relationship among a youth with SED, his/her family and involved 
child-serving systems to support the parent/caregiver in meeting their youth?s needs.  The ICC 
care planning process ensures that a care coordinator organizes and matches care across 
providers and child serving systems to enable the youth to be served in their home community.  

The care coordinator facilitates the development of a Care Planning Team (CPT) comprised of 
both formal and natural support persons who assist the family in identifying goals and 
developing an Individual Care Plan (ICP) and risk management/safety plan; convenes CPT 
meetings; coordinates and communicates with the members of the CPT to ensure the 
implementation of the ICP; works directly with the youth and family to implement elements of 
the ICP; coordinates the delivery of available services; and monitors and reviews progress 
toward ICP goals and updates the ICP in concert with the CPT.  The provision of ICC services 
reflects the individualized needs of youth and their families.  Changes in the intensity of a 
youth?s needs over time should not result in a change in care coordinator.  

Delivery of ICC may require care coordinators to team with family partners.  In ICC, the care 
coordinator and family partner work together with youth with SED and their families while 
maintaining their discrete functions.  The family partner works one-on-one and maintains 
regular frequent contact with the parent(s)/caregiver(s) in order to provide education and 
support throughout the care planning process, attends CPT meetings, and may assist the 
parent(s)/caregiver(s) in articulating the youth?s strengths, needs, and goals for ICC to the care 
coordinator and CPT. The family partner educates parents/caregivers about how to effectively 
navigate the child-serving systems for themselves and about the existence of 
informal/community resources available to them; and facilitates the caregiver?s access to these 
resources.

ICC is defined as follows:

1.   Assessment: The care coordinator facilitates the development of the Care Planning Team 
(CPT), who utilize multiple tools, including a strength-based assessment inclusive of the 
Child and Adolescent Needs and Strengths (CANS-MA version), in conjunction with a 
comprehensive assessment and other clinical information to organize and guide the 
development of an Individual Care Plan (ICP) and a risk management/safety plan.  The 
CPT is a source for information needed to form a complete assessment of the youth and 
family.  The CPT includes, as appropriate, both formal supports, such as the care 
coordinator, providers, case managers from child-serving state agencies, and natural 
supports, such as family members, neighbors, friends, and clergy.  Assessment activities 
include without limitation the care coordinator 
*	assisting the family to identify appropriate members of the CPT; 
*	facilitating the CPT to identify strengths and needs of the youth and family in 
meeting their needs; and 
*	collecting background information and plans from other agencies.
The assessment process determines the needs of the youth for any medical, educational, 
social, therapeutic, or other services.  Further assessments will be provided as medically 
necessary.

2.   Development of an Individual Care Plan: Using the information collected through an 
assessment, the care coordinator convenes and facilitates the CPT meetings and the CPT 
develops a child- and family-centered Individual Care Plan (ICP) that specifies the goals 
and actions to address the medical, educational, social, therapeutic, or other services needed 
by the youth and family.  The care coordinator works directly with the youth, the family (or 
the authorized healthcare decision maker), and others to identify strengths and needs of the 
youth and family, and to develop a plan for meeting those needs and goals with concrete 
interventions and strategies, and identified responsible persons  

3.   Referral and related activities:  Using the ICP, the care coordinator 
*	convenes the CPT which develops the ICP; 
*	works directly with the youth and family to implement elements of the ICP; 
*	prepares, monitors, and modifies the ICP in concert with the CPT; 
*	will identify, actively assist the youth and family to obtain, and monitor the 
delivery of available services including medical, educational, social, therapeutic, 
or other services; 
*	develops with the CPT a transition plan when the youth has achieved goals of 
the ICP; and 
*	collaborates with the other service providers and state agencies (if involved) on 
the behalf of the youth and family.

4.   Monitoring and follow-up activities: The care coordinator will facilitate reviews of the 
ICP, convening the CPT as needed to update the plan of care to reflect the changing needs 
of the youth and family.  The care coordinator working with the CPT perform such reviews 
and include 
*	whether services are being provided in accordance with the ICP; 
*	whether services in the ICP are adequate; and 
*	whether these are changes in the needs or status of the youth and if so, adjusting 
the plan of care as necessary.


Criteria
Admission Criteria
All of the following are necessary for admission to this level of care:
1.	The youth meets the criteria for serious emotional disturbance 
(SED) as defined by either Part I or II of the criteria below.

Part I:

The youth currently has, or at any time during the past year has 
had, a diagnosable mental, behavioral, or emotional disorder of 
sufficient duration to meet the diagnostic criteria specified within 
ICD -10 or DSM ?IV-TR (and subsequent revisions) of the 
American Psychiatric Association with the exception of other V 
codes, substance use, and developmental disorders, unless these 
disorders co-occur with another diagnosable disturbance.  All of 
these disorders have episodic, recurrent, or persistent features; 
however, they vary in terms of severity and disabling effects.

The diagnosable disorder identified above has resulted in 
functional impairment that substantially interferes with or limits 
the youth?s role or functioning in family, school, or community 
activities.  Functional impairment is defined as difficulties that 
substantially interfere with or limit the youth in achieving or 
maintaining developmentally appropriate social, behavioral, 
cognitive, communicative, or adaptive skills.  Functional 
impairments of episodic, recurrent, and continuous duration are 
included unless they are temporary and expected responses to 
stressful events in the environment.

Youth who would have met functional impairment criteria during 
the referenced year without the benefit of treatment or other 
support services are included in this definition.

OR

Part II:

The youth exhibits one or more of the following characteristics 
over a long period of time and to a marked degree that adversely 
affects educational performance: an inability to learn that cannot 
be explained by intellectual, sensory, or health factors; an 
inability to build or maintain satisfactory interpersonal 
relationships with peers and teachers; inappropriate types of 
behavior or feelings under normal circumstances; a general 
pervasive mood of unhappiness or depression; or a tendency to 
develop physical symptoms or fears associated with personal or 
school problems

The emotional impairment is not solely the result of autism, 
developmental delay, intellectual impairment, hearing 
impairment, vision impairment, deaf-blind impairment, specific 
learning disability, traumatic brain injury, speech or language 
impairment, health impairment, or a combination thereof.


2.	The youth:

a.	needs or receives multiple services other than ICC from 
the same or multiple provider(s)
OR
b.	needs or receives services from, state agencies,  special 
education, or a combination thereof;
AND 
c.	 needs a care planning team to coordinate services the 
youth needs from multiple providers or state agencies, 
special education, or a combination thereof  
 
3.	The person(s) with authority to consent to medical treatment for 
the youth voluntarily agrees to participate in ICC.  The assent of a 
youth who is not authorized under applicable law to consent to 
medical treatment is desirable but not required. 

4.	For youth in a hospital, skilled nursing facility, psychiatric 
residential treatment facility or other residential treatment setting 
who meet the above criteria, the admission to ICC may occur no 
more than 180 days prior to discharge from the above settings 
 
  
Psychosocial, 
Occupational, Cultural, 
and Linguistic Factors
These factors may change the risk assessment and should be 
considered when making level-of-care decisions.

Exclusion Criteria 
Any of the following criteria is sufficient for exclusion from this level 
of care: 
1.	The person(s) with authority to consent to medical treatment for 
the youth does not voluntarily consent to participate in ICC.
2.	The youth is in a hospital, skilled nursing facility, psychiatric 
residential treatment facility, or other residential treatment setting 
at the time of referral and is unable to return to a family home 
environment or community setting with community-based 
supports. 

Continued Stay Criteria
All of the following criteria must be met for continued treatment at 
this level of care:
1.	The youth?s clinical condition(s) continues to warrant ICC 
services in order to coordinate the youth?s involvement with state 
agencies and special education or multiple service providers.
2.	Progress toward Individualized Care Plan (ICP) identified goals is 
evident and has been documented based upon the objectives 
defined for each goal, but the goals have not yet been substantially 
achieved despite sound clinical practice consistent with 
Wraparound and Systems of Care principles OR
3.	Progress has not been made, and the Care Plan Team (CPT) has 
identified and implemented changes and revisions to the ICP to 
support the goals of the youth and family.

Discharge Criteria
Any of the following criteria is sufficient for discharge from this level 
of care:
1.	The youth no longer meets the criteria for SED. 
2.	The CPT determines that the youth?s documented ICP goals and 
objectives have been substantially met and continued services are 
not necessary to prevent worsening of the youth?s behavioral 
health condition.
3.	Consent for treatment is withdrawn. 
4.	The youth and parent/caregiver are not engaged in treatment.  
Despite multiple, documented attempts to address engagement, the 
lack of engagement is of such a degree that it implies withdrawn 
consent or treatment at this level of care becomes ineffective or 
unsafe.
5.	The youth is placed in a hospital, skilled nursing facility, 
psychiatric residential treatment facility, or other residential 
treatment setting and is unable to return to a family home 
environment or a community setting with community-based 
supports or ICC. 
6.	The youth turns 21.


MEDICAL NECESSITY CRITERIA
3/11/09