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Case Management Services

Targeted Case Management (TCM) ; Ramsey County
South Metro Human Services provides Case Management Services under a contract with Ramsey County to individuals who are 18 or older; are diagnosed with a serious and persistent mental illness and/or have significant functional impairment in three or more areas as determined by a functional assessment. Case management services are designed to help adults with serious and persistent mental illness in gaining access to needed medical, social, education, vocational and other necessary services as they relate to the client’s mental health needs.

Targeted Case Managers provide the following services:

  • Develop and implement the treatment plan that is based on a diagnostic and functional assessment.
  • Provide or ensure access to needed and eligible medical, vocational, social, educational, financial, legal, and housing and chemical dependency services.
  • Develop an Individual Community Support Plan for each client.
  • Make appropriate culturally sensitive referrals, and assist clients in gaining access to needed services.
  • Participate in the commitment process: provide testimony in probate court, compose required court reports, monitor stayed warrants and provisional discharge agreements, and assist pre-petition screening process as necessary.
  • Assume, with other members of team, responsibility for providing the services necessary to maintain and enhance each client’s ability to live as independently as possible.
  • Develop an individualized emergency support plan coordinated with community emergency support services.
  • Assist with housing issues and interface with HRA and PHA staff as well as landlords.
  • Collaborate with, support and provide education to family members and others interested in the client’s treatment and welfare when warranted.
  • Provide education to clients regarding the symptoms, course and treatment of their illness.

Referrals for case managment must be made to Ramsey County Mental Health Intake, 651-266-7890. A referral by a Mental Health Professional is required. This professional could be a psychiatrist, psychologist, nurse, or a social worker.


Assertive Community Treatment (ACT)
Assertive Community Treatment (ACT) is a form of case management; it is a model for providing comprehensive community-based treatment to persons with severe and persistent mental illness.

South Metro Human Services currently provides ACT services in Ramsey, Hennepin and Anoka counties. The ACT team is a multidisciplinary group organized as mobile mental health service providers. The ACT multidisciplinary team includes a psychiatrist or certified nurse practitioner with authority to prescribe medications; registered nurses; case managers with specialties in mental health, chemical dependency, and vocational support; administrative staff; and a team leader who is a Mental Health Professional. They function interchangeably to provide treatment, rehabilitation, and support services that persons with severe mental illness need to live successfully in the community. Services are continuous and long-term. ACT services are intended primarily for individuals who are 18 or older with psychiatric illnesses that are most severe and persistent including schizophrenia, schizoaffective disorder, or bipolar disorder.  Referrals should be made to the host County's human services department.

The primary goals of ACT treatment are:

  • To lessen or eliminate the debilitating symptoms of mental illness and to minimize or prevent repeated acute episodes of the illness.
  • To meet basic needs and enhance quality of life.
  • To improve functioning in adult social and employment roles and activities.
  • To obtain and keep independence in the community.
  • To lessen the family’s burden of providing care.

The majority of the ACT services are provided in the client’s home, neighborhood, employment sites, or in places where people spend their leisure time. ACT provides services wherever clients need those services. If a client is hospitalized, the team will facilitate admission, treatment, and discharge and support the person throughout the entire inpatient process.

Referrals for ACT teams come from the Team’s county of financial responsibility. Individuals are reviewed by that County’s intake process and referred to the ACT team for assessment to determine if an ACT team is appropriate and beneficial for the individual.

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