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Friday, October 31, 2025

CalAIM Provider Learning Circle

Quality Documentation Training for Case Managers:

Why it Matters…

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Team Supporting Today’s Call

Berenice Herrera-Lopez

Programs Director

Maria Estela Jerezano

Sr. Program Coordinator

Guillermo De La Riva

Operations Coordinator

Esmeralda Aguilera, LCSW, C-ASWCM, ACM-SW, CCM

Consultant

Darlene Torres Voss, MSW

Consultant

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Learning Objectives

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By the end of this session, participants will be able to:

Understand and apply the Golden Thread concept in documentation.
Identify and correct breaks between assessment, plan, and notes.
Strengthen the visibility of their work through clear, outcome-focused notes.
Align documentation with Medi-Cal ECM quality standards.

Welcome everyone!

Today’s session is about connecting the “why” behind our documentation to the how of writing it well. We’ll explore the Golden Thread—a concept that ensures our assessments, care plans, interventions, and notes all connect to tell your client’s story clearly and meaningfully.�This isn’t just about compliance—it’s about showing the value of the work you do every day as case managers.

By the end of today, you’ll be able to:

Understand what the Golden Thread means and how to apply it.
Identify where the “thread” sometimes breaks in documentation.
Strengthen how your notes reflect outcomes and the impact of your work.
Align your documentation with Medi-Cal- ECM quality standards.

�Think of this session as a chance to fine-tune your documentation so that it truly shows your impact on your clients’ lives.

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Why It Matters

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Documentation tells the story of our client’s journey.
It ensures the care team sees the whole picture.
It protects both the client and the provider.
It’s how we demonstrate the value of case management in improving outcomes

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The Golden Thread: What It Is

A clear logical link between:

Comprehensive Assessment

What’s going on

Care Plan

What we’re working toward

Interventions

What we’re doing

Progress Notes

What’s changing

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Why It Matters to Case Managers

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Makes our work visible and measurable.
Shows medical necessity and purpose for every service.
Reduces duplication and confusion across systems (ECM, BH, primary care).
Strengthens client trust — “they see me, not just my chart.”

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��

The Golden Thread in Action

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Assessment

Goals

Interventions

Progress

Outcomes

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Assessment: The Foundation

Captures strengths, risks, and barriers.
Identifies why case management is needed.
Leads directly to measurable goals.

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Care Plan: Turning Needs Into Goals

Each goal ties directly to an assessment finding.
Use SMART format (Specific, Measurable, Achievable, Relevant, Time-bound).
Assign responsible party (case manager, client, partner agency).

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Interventions: What We Do

Reflect skill-based activities (not clerical).
Should show how you’re addressing the goal.
Include collaboration, coordination, and advocacy.

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Progress Notes: Evidence of Change

Each note must connect back to a care plan goal.
Show what’s improving, what’s not, and next steps.
We suggest to use a note format to stay consistent.

Does your organization use a note format?

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Progress notes are where we demonstrate change over time — they’re the evidence that our interventions are working.

Each note should clearly connect back to at least one care plan goal. This keeps the documentation consistent and helps anyone reviewing the chart immediately understand what the client is working toward.

When writing a progress note, think about these three questions:

What’s improving?

What’s not improving or still a barrier?

What’s the next step?

These three points create a simple but powerful story of progress.

Finally, using a consistent note format, like DAP or SOAP, helps every case manager write notes that are easy to read and audit-ready.

(Pause and engage) — Ask: ‘Does your organization currently use a note format? How consistent is it across programs?’

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Core Note Documentation Elements

Client Information:

Client Name / DOB / Program / Population of Focus (POF)
Date of Service & Type of Contact (in-person, phone, field, etc.)

Reason for Visit/Contact: Briefly state why today’s encounter happen.

Presenting Concerns/ Active Problems: List key issues or needs discussed

Social & Environmental Factors: Include living situation, family or caregiver context, supports, or cultural factors impacting care.

Assessment / Case Manager Observations: Describe your professional impression of client progress and barriers.

Case Collaboration / Coordination: Document coordination with other providers, community partners, or MCP staff.

Interventions / Actions Taken: Summarize what you did during this encounter.

Patient / Client Goals: Note which care plan goals were addressed and progress made.

Plan / Next Steps: List what’s next and who’s responsible.

Other Details

Diagnosis / Eligibility Justification:
Time Spent: Document total direct + indirect time.

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Let’s walk through the core elements that should appear in every case management note — no matter the format or system your organization uses.

Think of this as your checklist for capturing a complete and compliant encounter.

Start with the basics:

Client Information — This identifies the record and helps link services back to the right Population of Focus and services. As well, as date and type of contact

Reason for Visit — Always explain why the encounter is happening; that’s what establishes medical necessity.

Next, document the Presenting Concerns and Social & Environmental Factors — this tells the story of what’s happening in the client’s life that impacts health or stability.

The Assessment or Observations section is where your professional judgment comes in. It’s your interpretation — how is the client progressing, and what still needs attention?

Then, under Case Collaboration, capture any coordination with other providers or partners. This is a key part of the ECM model — it shows that care is integrated, not siloed.

The Interventions and Actions Taken section should describe what you did — coordination, advocacy, education, or linkage.

Tie that directly to the Client Goals you’re supporting from the care plan. This connection is what keeps the Golden Thread strong.

Finally, include your Plan / Next Steps, any relevant Diagnosis or Eligibility, and Time Spent (both direct and indirect).

Remember — each of these elements works together to show a full picture of your work and the client’s progress. It’s how we demonstrate the why, what, and impact of case management.”

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Common Breaks in the Thread

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Area	Common Error	How to Repair
Assessment	Vague or missing need	Restate clear reason for service
Plan	Goal doesn’t match problem	Re-link goal to identified barrier
Note	No reference to plan	Add the goal name or number
Outcome	No updates	Summarize progress at each review

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Why It Matters for Compliance & Quality

Aligns with Medi-Cal and MCP audit standards.
Demonstrates medical necessity and effective service delivery.
Supports funding sustainability and program credibility.

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Case Scenario Exercise #1

Children and Youth Involved in Multiple Systems

Scenario:�Aiden, 15, is on juvenile probation, has an IEP at school, and is currently in foster care. He’s showing signs of depression and missing school frequently. The foster parent feels unsupported navigating all the systems.

Golden Thread Focus:

Assessment: Emotional distress, system overload, academic challenges, caregiver stress.
Goal: Improve school attendance and emotional regulation.
Intervention: Coordinate between school counselor and probation officer; connect foster parent with CBO support group; schedule therapy intake.
Progress Note:

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This case example helps us practice applying the Golden Thread in a real-world situation — especially with one of our most complex populations: youth involved in multiple systems.

Here we have Aiden, age 15. He’s juggling multiple systems — juvenile probation, special education through an IEP, and the foster care system. On top of that, he’s showing signs of depression and missing school frequently. His foster parent feels overwhelmed and unsupported.

This scenario represents what many of our ECM case managers face — where no single provider has the full picture.

Let’s walk through it using the Golden Thread framework:

Assessment: What are the main issues? We see emotional distress, school challenges, and caregiver stress. The key is to document these clearly — they justify the need for case management.

Goal: What are we working toward? Here, improving school attendance and emotional regulation — those are measurable and linked to the assessment findings.

Intervention: What’s our role as the connector? Coordinating between the school counselor, probation officer, and connecting the foster parent with a support group are concrete, skill-based interventions. They show active care coordination, not just referrals.

Progress Note: This is where you capture change — for example, if Aiden starts attending school more regularly or the caregiver reports feeling more supported, that’s progress you document clearly.

(Pause to engage audience)�Ask: “What would you include in your note for this visit?” or “How might you keep the Golden Thread visible when multiple systems are involved?”

The goal of this exercise is to help case managers see how every part of their documentation — from assessment to progress note — tells a consistent story of support and impact.”

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Case Scenario Exercise #2

High-Risk Adults with Chronic Medical Conditions

Scenario:�Linh, 64, has congestive heart failure and diabetes. She struggles to manage medications and diets, lives alone, and has transportation barriers. Recently hospitalized for fluid overload.

Golden Thread Focus:

Assessment: Health literacy barriers, limited social support, high readmission risk.
Goal: Reduce hospital readmissions and improve self-management.
Intervention: Conduct medication reconciliation, coordinate home health visit, arrange paratransit rides to clinic.
Progress Note:�

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Here’s another case scenario — one that reflects many of the clients our ECM teams serve.

Meet Linh, age 64. She’s living with congestive heart failure and diabetes. She lives alone, has limited transportation, and struggles to keep track of her medications and diet. She’s been hospitalized recently for fluid overload.

This case represents a high-risk medical client — someone who clearly meets ECM eligibility because of complex chronic conditions and repeated hospitalizations.

Let’s break it down through the Golden Thread:

Assessment: What do we see here? Linh has health literacy barriers, limited support, and a high risk for readmission. That assessment should be documented clearly to show why ECM services are medically necessary.

Goal: Her goal is to reduce hospital readmissions and improve self-management. Notice that this goal is measurable — we can track readmissions, and we can assess whether she’s managing her medications and diet better over time.

Intervention: Here’s where your case management skill comes in. You’re not just calling to “check in.” You’re providing structured coordination: conducting a medication reconciliation, scheduling home health visits, and arranging alliance rides for medical appointments. Each of these shows active care coordination tied to her goal.

** I do want to point out medication reconciliation in this scenario because we need to be careful with this intervention and stay within our scope. Case managers do not prescribe, adjust, or directly manage medications, but they play a key supportive role in ensuring that clients understand and can safely follow their prescribed medication regimens.

Allowed Activities

Collecting and confirming medication lists with the client, caregiver, and available records (e.g., EHR, hospital discharge summaries).

Verifying understanding of prescribed medications, including purpose, dosing schedule, and side effects.

Identifying discrepancies between medications listed by providers and reported by the client (e.g., missed updates, duplications).

Notifying care team/providers when concerns or discrepancies are identified.

Coordinating follow-up with PCP or behavioral health provider if medication questions or issues arise.

Providing education on how to store, take, and manage medications (based on approved and standardized information).

Facilitating access, such as helping clients refill medications or troubleshoot barriers like pharmacy issues or coverage gaps.

Documenting changes and communication in ECM records and care plans.

Not Allowed

Advising clients on clinical decisions such as changing medication type or dose.

Determining clinical appropriateness of medication use.

Diagnosing side effects or medical conditions.

Writing prescriptions or changing orders.

Now your Progress Note: This is where you would record what’s changing — for example, if Linh started using a pill organizer, if her weight stabilized, or if she successfully made her last clinic visit. Those are measurable progress points.

(Pause and engage) — Ask the group:�“What would you document if you followed up with Linh a week later?”�“How can you show progress even if her health condition hasn’t changed yet?”

Encourage them to think about how every action — even small steps like a transportation coordination call — ties back to the goal and reinforces the Golden Thread of continuity and impact.”

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Case Scenario Exercise #3

Adults with Serious Mental Illness (SMI)

Scenario:

Maria, age 47, lives alone and has schizophrenia. She often forgets to take her medication and has had two recent ER visits for agitation. She’s socially isolated and her utilities were recently shut off due to unpaid bills.

Golden Thread Focus:

Assessment: Cognitive barriers, poor medication adherence, limited social supports, housing instability.
Goal: Improve medication adherence and maintain stable housing.
Intervention: Coordinate with psychiatry for medication management, set up automatic bill pay with PG&E, link to peer support group.
Progress Note:�

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This scenario focuses on Maria, a 47-year-old client living with schizophrenia. She lives alone, forgets to take her medication, and has had two recent ER visits for agitation. She’s also socially isolated and recently had her utilities shut off — so we can see multiple overlapping risks here.

For many ECM clients, this combination of behavioral health, social, and environmental barriers is what makes care coordination so critical.

Let’s walk through how the Golden Thread applies:

Assessment: We start with identifying the key issues — cognitive barriers, poor medication adherence, limited social supports, and housing instability. Documenting these clearly justifies the intensity of case management support.

Goal: The care plan goal focuses on improving medication adherence and maintaining stable housing. Both are measurable and directly tied to the assessment findings.

Intervention: Here’s where the case manager’s role becomes visible. Coordinating with psychiatry for medication management, setting up automatic bill pay with PG&E, and connecting Maria to a peer support group — these are skill-based, solution-oriented actions that reflect both clinical and social care coordination.

Progress Note: This would capture what’s improving — for example, if Maria started attending her appointments, hasn’t missed doses for a week, or if her utilities were restored. Even small wins like returning a phone call or engaging with a peer group are evidence of progress.

(Pause and engage) — Ask participants:�“How would you show Maria’s progress in your note?”�“What barriers might come up again, and how would you reflect that in your assessment section?”

The point of this exercise is to help case managers see that documentation isn’t just about checking a box — it’s about showing stability, resilience, and coordination over time. Every part of the note should tie back to the care plan and demonstrate that ongoing need for ECM-level support.”

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Boundaries Are Essential Because…

Boundaries support:

Mutual respect and professionalism
Consistency and equity in services
Protection of personal space and energy
Clarity around role and scope of work
Long-term sustainability and work-life balance

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Healthy Boundaries

Professional
Clear
Sustainable

Let’s take a few minutes to talk about boundaries — because they are absolutely essential in case management.

Healthy boundaries are what keep our relationships with clients professional, clear, and sustainable.

They allow us to show care and empathy without crossing into overextension or burnout. When we maintain professional boundaries, we’re modeling consistency and self-respect — and clients learn they can depend on us to be steady and reliable.

Boundaries also support equity. Every client deserves consistent treatment and access to services, regardless of how assertive or quiet they might be. Having clear boundaries helps ensure that our decisions and time are based on need and scope

They also protect our personal space and energy. This work can be emotionally heavy. Boundaries are how we protect our sustainability and preserve the compassion that brought us into this field.

Finally, they create clarity. When our role and limits are clear, everyone — clients, providers, supervisors — understands what to expect. That clarity builds trust and prevents confusion.

Remember: Healthy boundaries don’t create distance — they create safety and consistency. They help us stay effective and grounded so we can continue doing this meaningful work long-term.”

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Setting and Communicating Boundaries

Boundaries are built through:

Defining your role clearly – know your scope and limits
Communicating expectations early – normalize structure
Using boundaries as a tool for equity – same standards for all clients
Practicing mindful self-disclosure – share only when it serves the client
Preparing for discharge early – closure is part of care

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“Now that we’ve talked about why boundaries are important, let’s focus on how we set and communicate them.

Boundaries aren’t just rules — they’re part of our professional practice. They keep our relationships clear, equitable, and sustainable.

First, define your role clearly. Be explicit about what your position includes and what it doesn’t. This avoids confusion and sets healthy expectations from the beginning. For example, instead of saying ‘I’ll do my best to help with anything,’ say ‘My role is to coordinate care and connect you with the right supports.’

Second, communicate expectations early. Normalize structure in your conversations. Let clients know how and when you’ll follow up, your work hours, and what they can expect from your program. Clear communication reduces misunderstandings and builds trust.

Third, use boundaries as a tool for equity. When we apply the same professional limits and standards for all clients, we ensure fairness. Boundaries prevent us from overextending for one client and unintentionally neglecting another.

Fourth, practice mindful self-disclosure. It’s okay to share something about yourself if it helps the client — but it should always serve their needs, not yours. Before sharing, ask yourself: Is this for me, or for them?

And finally, prepare for discharge early. Closure is part of the case management process, not a surprise ending. Bringing it up early reinforces that the relationship is goal-focused and time-limited — which actually helps clients build independence.

(Pause for reflection)�Ask the group: What boundary-setting statements have worked well for you in your role? or What feels most challenging to communicate clearly to clients?

Remember: clear boundaries don’t limit your care — they protect your ability to keep caring.”

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Healthy Boundaries = Sustainable Practice

“You can’t pour from an empty cup.”
“Reach trust through consistency.”
“Boundaries are a form of self-care and advocacy.”
“When we stay within our scope, we stay effective.”

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“I want to close this section by reminding us that healthy boundaries aren’t about distance — they’re about sustainability.

The first quote, ‘You can’t pour from an empty cup,’ is something many of us forget in this work. Case management is heart work — we give a lot of emotional energy — but we can’t keep giving if we don’t recharge ourselves. Boundaries help preserve that energy.

‘Reach trust through consistency’ reminds us that clients don’t need us to be available 24/7 — they need us to be reliable and predictable. Consistency builds trust more than overextension ever can.

‘Boundaries are a form of self-care and advocacy.’ When we set limits, we model healthy behavior for clients who may have never experienced boundaries before. It shows them that it’s okay to say no, and that caring for yourself is part of success.

And finally, ‘When we stay within our scope, we stay effective.’ Overstepping can blur accountability, confuse clients, and lead to burnout. Staying grounded in your scope keeps your work clear, measurable, and impactful.

(Pause)�Ask the group: Which of these quotes resonates with you most right now? or What boundary do you want to strengthen to make your practice more sustainable?

Remember, boundaries are not barriers — they are the structure that keeps us steady, effective, and compassionate.”

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Quick Recap: Why It Matters

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Clear story of need and impact
Shows our work’s value
Builds client trust and continuity
Keeps us audit-ready

As we wrap up, let’s bring it back to why this work matters.

When we talk about the Golden Thread, it’s not just a documentation tool — it’s how we tell the story of the clients we serve.

• It gives a clear story of need and impact. Our documentation shows where clients started, what we did, and how things have changed. It connects the dots for anyone reviewing the record — whether it’s a fellow case manager, MCP, or auditor.

• It shows our work’s value. Every note you write demonstrates the expertise, care coordination, and advocacy that case managers provide — things that often happen behind the scenes.

• It builds client trust and continuity. When notes are clear and connected, any team member who reads the chart can step in and pick up where the last person left off. That continuity creates safety and consistency for our clients.

• And finally, it keeps us audit-ready. When our documentation follows the Golden Thread, we don’t have to scramble during chart reviews or compliance checks — it’s already there, clear and defensible.

So remember: documentation isn’t just paperwork — it’s advocacy on paper. It’s how we make invisible work visible and show that every connection, every coordination, every call matters.”

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Thank you for joining!

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For any questions, please contact the HIP Team at path@hipscc.org.

Care Plans (cont.) - Social Drivers of Health (SDOH) Codes, Screening Tools, and Documentation of Medical Necessity

Fri, 12/5, 12 -1 PM via Zoom: Register Here

Register for future sessions below:

Comprehensive Assessment, Care Plans, & Transition of Care

Fri, 11/14, 12 -1 PM via Zoom: Register Here

Case Management Notes & Disenrollment/Discharge Summaries

Fri, 12/12, 12 -1 PM via Zoom: Register Here

As we wrap up, let’s bring it back to why this work matters.

When we talk about the Golden Thread, it’s not just a documentation tool — it’s how we tell the story of the clients we serve.

• It gives a clear story of need and impact. Our documentation shows where clients started, what we did, and how things have changed. It connects the dots for anyone reviewing the record — whether it’s a fellow case manager, MCP, or auditor.

• It shows our work’s value. Every note you write demonstrates the expertise, care coordination, and advocacy that case managers provide — things that often happen behind the scenes.

• It builds client trust and continuity. When notes are clear and connected, any team member who reads the chart can step in and pick up where the last person left off. That continuity creates safety and consistency for our clients.

• And finally, it keeps us audit-ready. When our documentation follows the Golden Thread, we don’t have to scramble during chart reviews or compliance checks — it’s already there, clear and defensible.

So remember: documentation isn’t just paperwork — it’s advocacy on paper. It’s how we make invisible work visible and show that every connection, every coordination, every call matters.”