Case management services are provided to people who are eligible for receiving developmental disability services.

The role of the community case manager involves working with participants and others that are identified by the participant, such as family members, in developing an individualized support plan and assisting the person to implement that plan. The community case manager's primary customer is the person with disabilities and their families. Community case managers will work closely with the participant to assure his or her ongoing satisfaction with the process and outcomes of the supports, services and available resources. The primary role of the community case manager is to assist in identifying and implementing support strategies that reflect the participant's personal vision for a desired life.

The community case manager needs to balance several roles and responsibilities. These include maintaining relationships with the participant's family and developmental disability services as well as other service providers and the community at large.

The community case manager, using the person centered planning process, will work with the participant, and others identified by the participant, in the development of an individualized support plan. The case manager will assist the participant, and others, in identifying support strategies that can be implemented to guide the participant to attain self-identified goals and wishes. Support strategies must incorporate the principles of empowerment, community inclusion, health and safety assurances and the use of natural supports. The case manager will analyze the outcomes of the supports and services implemented, and will monitor available resources to support the participant's plan.

Strategies and implementation plans must be comprehensive and address the following: health and safety of the participant; housing and employment; social networking; scheduling and documentation of appointments and meetings, including on-going person centered planning; utilization of natural and community supports; and the quality of the various supports and services utilized by the participant.

Contact with consumers should occur in the home, work, and community. Often, there are different issues for the person in each environment.

During contact with the consumer, attention needs to be paid to:

  • Programming/work needs
  • Physical well-being
  • Emotional well-being
  • Social well-being
  • Environment (home and work)
Communication with staff (if applicable), family and peers

It is important for the community case manager to develop positive relationships with the consumer's primary supports. This will help to facilitate good communication to help support the consumer's well-being.


Case management services include the following:

  • Development and implementation of a service plan under the direction of the person and in accordance with established policies.
  • Coordination of the service providers and resources identified in the service plan.
  • Linkage of the person with the appropriate agencies, community resources and informal support systems, including referrals to transportation services.
  • Monitoring the person's progress toward the achievement of objectives specified in the service plan. The service plan will be re-evaluated as often as is specified in the plan.
  • Health and safety needs that require the support and protection of the person by Developmental Disability Services.


Community case managers will plan with individuals for the coordination and delivery of supportive and other services through the development of an individual support plan. The type of plan, participants and agenda at the planning meeting will be selected by the individual and/or their guardian. The personal planning process will be:

  • Understandable and in plain language or if the individual is deaf, non-verbal, signing or speaks another language; the process will include qualified interpreters.
  • Focused on the person's choice.
  • Reflective and supportive of the person's goals and aspirations.
  • Developed at the direction of the consumer and include people the consumer chooses.
  • Flexible enough to change as new opportunities arise.
  • Reviewed according to a specified scheduled and by a person designated for monitoring.
  • Inclusive of the desires and needs of the person without respect to whether those desires are reasonable, achievable or the needs are presently capable of being addressed.
  • Inclusive of provision for assuring each person's satisfaction with the quality of the plan and the supports he/she receives.
The plan will focus on the supports identified by the individual. The plan will be written and approved by the consumer/guardian and the action plan will be entered into EIS within 30 days of the meeting date. The plan may be facilitated by the consumer, a case manager, other agencies providing major services to the individual, family members or other persons chosen by the consumer. The planning team will always develop a service plan or action plan which outlines the agreements reached by the team. The planning team will follow the needs/desires policy in regards to time frames for identified needs and interim plans for unmet needs.

For further information on CCM services, please feel free to contact

Houlton Office covering Aroostook County and Penobscot County: Lisa Surran, CCM Program Manager, at (207) 532-1245, extension 5 or via email at

Brewer Office covering Penobscot (from Medway South) and Piscataquis Counties: Samantha Kelly, CCM Program Manager, at (207) 262-3850, or via email at