Care Management 101
There are many billable efforts for diligent search; name three.
Attempted FTF
RHIO search
Collateral from 5055
When should you set up your first IDTM with a newly enrolled client?
What should be included in a discharge packet?
Letter to client
Letter(s) to providers
NOD for Disenrollment
Discharge Summary
RHIO consent
Functional Assessment consent
Withdrawal of Consent
Care Plan (if there is one)
*Extra 100 points if they can name all*
When uploading an updated 5055, what should be included?
All 3 pages of the consent.
Pg 1 - Health Home Sharing consent (enrollment)
Pg 2 - info page
Pg 3 - Provider page (all of them)
When should you talk to your supervisor about a potential incident report?
As soon as you are aware of it
SRI's (Serious Reportable Incidents) should be reported within 24 hours of discovery. Name three SRI's.
Client Death
Violation of PHI
Abuse/neglect by staff
Suicide attempt
Perpetrator of crime
AWOL / missing person
When a client is an excluded setting, what should you do?
Connect with excluded setting and/or at LEAST monthly to check on status of clients potential discharge.
What are the only 3 exceptions to the 10 day rule for discharges
Client death
Client withdrew consent
Transfer to another agency
*these case can close effective immediately*
When should a 5055 be updated?
Any change to consented parties
and/or
Annually (at minimum)
When should your discharge paperwork be mailed out to your client?
Two weeks prior to the end of the month!
When should a care plan be updated?
Any significant life event/change
and/or
Before the expiration of their goals
(B Schrader)
What should be sent out prior to completing an IDTM meeting?
Invite letter to invitees
Case Summary Form
Scenario: Your client's emergency contact (wife) calls you and says that her husband is no longer in need of services and would like to close his case. How do you respond?
Tell his wife that we must speak with our client (husband) to confirm before we are able to begin the discharge process.
How do you update a 5055 correctly?
Use original provider page (do not change pg 1)
Add newly consented parties / cross out old providers
Client initials each line and date
When you receive a new case, how long do you have to contact and schedule with them?
3 days (best practice)
CORE services are available for those clients who are HARP eligible or enrolled; name all the CORE services.
Peer Support
PSR (psychosocial rehabilitation)
CPST (Community Psychiatric Support & Treatment)
FST (Family support and Training)
Scenario: Family member of client calls you, and asks you to reach out to the client's therapist to reschedule their appointment. How do you handle this?
Tell them you have to check to see if you have consent to speak with them.
CES (Continued Eligibility Screening) tool is completed to determine the clients need for ongoing services.
What are all possible outcomes?
What happens next?
1) Rec. continued services - complete CES in 6 mos.
2) More info needed - discuss with supervisor
3) Rec. disenrollment - discuss with sup/close in 60 days.
4) HH+ (N/A)
CM Mary and CM Joe share a family on their caseloads.
Mary works with the Wife, and Joe has the Husband.
Mary overhears Joe talking on the phone in the office to the Husband about wanting a divorce from his wife.
What should Mary do with this information?
NOTHING!
(Why? discussion)
Scenario: You have discharge paperwork to complete by the 14th. Your supervisor is out of the office from the 12th - the 19th. What do you do?
OR
Ask another supervisor to sign off so it is mailed on time
What is the difference between Diligent Search for CNYHHN clients vs Bassett clients?
- Bassett requires MCO to be contacted during month 1
- Bassett - 2 months; CNY - 3 months
What steps do you take after receiving RHIO/MCO/Foothold/Netsmart alerts?
Follow up with client/facility same day
Complete progress note
Complete Care Transition or Hallmark Event
Incident report if needed (talk to sup)
Scenario: Your client, Macy, has informed you that she would like to transfer to the Neighborhood Center. When asked why she wants to transfer, she tells you that she receives MH counseling there. How do you respond?
- Ensure she was not pressured into this decision by other agency
- Supervisor will call to discuss/complete Transfer forms
- CM must meet with client to have 5055 updated with receiving agency listed.
Scenario: You receive a new case, with all paperwork stating your client's name is Olivia. When you meet with them, you find out that he goes by Olly and is a transmale. Olly has an issue with "Olivia" being written on his consents. What do you tell him?
Once name is legally changed, update consents!
When are timecards and mileage reimbursement forms due?
WHEN THE CALENDAR INVITES SAY THEY'RE DUE.
timecards: by noon on Friday of non pay week
mileage: by noon on the 5th of each month
*Supervisors need time to review and potentially ask for corrections*