Care Management Program Description

MonmouthCares is the Care Management Organization (CMO) for Monmouth County, New Jersey.  It is a nonprofit organization that is responsible for face-to-face care management and comprehensive service planning for youth and their families with complex needs.   We follow the Wraparound evidence-based model in delivering care management services in the community, which include but are not limited to, comprehensive assessment, Individual Service Plan design and implementation, advocacy, and family support, monitoring, and information management.  MonmouthCares is also responsible for local community resource development.

In addition, MonmouthCares has a designated Behavioral Health Home (BHH) as part of its service. The BHH serves as a bridge that connects prevention, primary care, and specialty care for those youth/families enrolled that meet eligibility requirements and have Medicaid insurance.  The BHH team includes a registered nurse and health/wellness coaches. 

MonmouthCares serves youth between the age of 4 and until their 21st birthday.    To be eligible for services, youth must manifest moderate to severe emotional or mental health challenges consistent with a DSM5/ICD 10 diagnosis.  MonmouthCares also serves youth with developmental disabilities and/or substance use.  Our care management services are delivered in the community.  Our hours of office operation are Monday – Friday 9 am to 5 pm.  However, MonmouthCares provides after-hours access to emergency management 24/7 365 days a year.   

Care Management is delivered through face-to-face engagement with the family minimally on a monthly basis.  Phone contact is maintained at least weekly or as needed.  Individual service planning, after the initial 30-day plan, occurs every 90 days.  Care managers collaborate and communicate with system partners/child family team members including school, probation, and clinical supports (psychiatrist, therapist, behavioral assistant, outpatient mental health providers).

Care Management is billed through New Jersey Medicaid and the CSOC (Children’s System of Care) provides contracted money known as Flex Funds to cover nontraditional expenses not paid for through Medicaid. 

Referrals are generated through a variety of ways.  All referrals are generated through PerformCare, a Contracted System Administrator.  A family can request a biopsychosocial assessment from a licensed clinician who will determine if the youth’s needs rise to a CMO referral.  Mobile Response and Stabilization services can document the need for a CMO level of care for families they are working with.  Substance use providers and outpatient mental health clinics, as well as Children’s Crisis Intervention and Inpatient Services (CCIS) can make a referral to PerformCare for CMO level of care. 

Every family enrolled in MonmouthCares receives a copy of our Family Guide to Wraparound which details who we are and explains our Wraparound process.  It informs the family of the expectations of their care manager and family support partner.  Information regarding community resources is provided as well as youth and family’s rights including MonmouthCares’ formal complaint procedure.  The rights of the person served (our youth and families) are reviewed annually with the youth and family.   Families also have access to our website for information about our mission, values, service description, practice model, and contact information.