Page 2396

emotional, and mobility areas. A case manager who meets the requirements of (h) of this section shall collect data from a family interview, existing available records, and the needs assessment. (e) The case manager shall develop an individualized family service plan (IFSP) under AS 47.20.100 in conjunction with the family and other team members involved to identify goals, outcomes, objectives, and issues identified during the intake and needs assessment. Developing the individualized family service plan includes

(1) determining activities to be completed by the case manager in support of the child and family, including obtaining appropriate health, mental health, social, educational, developmental, and transportation services to meet the child’s needs;

(2) coordination and monitoring of services provided;

(3) establishing and maintaining, with individuals and agencies, a referral process that avoids duplication of services to the child and family;

(4) planning that identifies needs, goals, objectives, and resources in a coordinated, integrated fashion with the family and other involved agencies;

(5) implementing the individualized family service plan and monitoring its status; and

(6) supporting the family to reach the goals of the individualized family service plan. (f) The case manager, in consultation with the family and other team members involved, shall monitor whether the services continue to meet the child’s and family’s needs. The case manager shall make adjustments and new or additional referrals to adequately meet the child’s and family’s needs. (g) The targeted case management services must

(1) assist families of eligible children in gaining access to infant learning program services under AS 47.20 and 7 AAC 23 and other medical or social services identified in the individualized family service plan;

(2) coordinate and monitor the delivery of infant learning program services under AS 47.20 and 7 AAC 23 and other medical or social services that the child needs or is being provided;

(3) inform families of availability of advocacy services; and

(4) provide maintenance of a record of case management activities in each child’s file. (h) A case manager must

(1) be an employee or contractor of the infant learning program grantee; and

(2) have demonstrated knowledge and understanding about

(A) the infant learning program under AS 47.20 and 7 AAC 23;