Welcome Appt
Activity code used to document welcome appointments
CCOTH
If it is telehealth, utilize CMTCM service code with accurate action words (ex: link)
3rd party system to look up admit reasons
Health Information Exchange (HIE)
What does CCCP stand for?
Care Coordination Care Pathway
CAR score that CNs monitor
Med/Physical
CAR scores of 30+ is considered high and needs monitoring
Action words for care coordination
Monitor, follow-up, and coordinate care
Purpose of welcome appointment
To create a welcoming environment
True or False: We must follow-up on Outpatient care frags.
False: We only need to follow-up on ER/IP care frags.
Outpatient care frags do not pop up on the reports.
How many CCCPs should be open in a client's chart?
ONE. It stays open while the client is actively in treatment services.
How many days do we have to follow-up on care frag events?
7-30 days. We want to aim for 7 days to ensure continuity of care.
How to document time completing MCD applications
Staff time: MCD APP
App clients can download to their personal devices to connect with treatment team, have telehealth appointments, sign documents, and access to resources
ApexCare
True or False: When following up with a client for care frags, we must disclose details about HIE and ER/IP visit.
False. We let client disclose independently. We do simple check-ins on services internally and externally to coordinate care.
The 4 statuses
Identify, Follow-Up, Monitor, and Complete
How many days do we have to ensure client receives follow-up service after being discharged from crisis/IP?
7 days. We also want to ensure we are providing continuity of care to prevent readmission for at least 180 days.
Service code used for linking letters
CMTCM
Method used to implement change talk
Motivational Interviewing
What is it called when only sharing information that pertains to treatment services?
Minimum necessary
What status: Client has many needs pertaining to this loop and may need additional support in this area.
Monitor
How many days do we have to follow-up on OUTPATIENT Crisis Service?
8 days. They are automatically enrolled in the "8-Day Follow Up" pathway.
Case Management vs Care Coordination: What's the difference?
Case Management: A service that is immediate, planned, and intention of closing the "loop".
Care Coordination: Activity that is ongoing. "It's just what we do."
Does the welcome occur before or after INTKE?
Bonus: What is the document attached to the treatment plan when obtaining preferences of treatment?
It can occur before or after.
Bonus: Service Matrix
You see a client has appeared multiple times in a care frag report. Should you track all of them in the CCCP?
If admit date is the same, it is for one visit. Therefore, we only need to add the loop once. If they are going in and out of the ER for the same reason, we can set the loop to monitor rather than adding multiple loops to follow-up on.
What are we tracking with CCCP?
Any care coordination needs. External and/or Internal. It's up to you on how to manage and monitor it.
What does ETPS stand for?
Enhanced Tier Payment System. It's a structured rating system that supports decision-making, documentation, and advocacy, making sure clients receive the right level of care and resources to meet their needs.
How would you differentiate between Agency ROI and Care Coordination ROI?
Agency ROI: Medical records can be released
Care Coordination ROI: Verbal only