Care Plans
The kind of goals that should be in a care plan.
What are SMART goals? Specific, Measurable, Achievable, Realistic, Time-bound
Medication Reconciliation Step Actions
What is
complete medication form (in med rec task),
set task to reoccur annually,
(refer to pharmacy if: 10+ meds, 3+ antipsychotic, 3+ antidepressants, under 18 and 6+ meds)
complete med risk assessment and upload to task, (if score of 6 or higher- present to clinical staffing; if less than 6 complete task),
document score in med rec task
Timelines: (from assignment)
2 business days
30 days
60 days
What are:
record review, initial outreach (attempt)
CMCA & Supplement completion
Care plan published
What step should be completed before submitting 1915i assessment to process Smartsheet
Send to supervisor for approval via email
When notes are due
What is 2 business days
Before you submit a plan for audit, you should do these things.
What are:
make sure the plan team is correct/updated
make sure plan meeting date/s are reflected
'view plan' to ensure there are no errors or incomplete fields/sections
Where documents are uploaded
What is
TBS- any clinical docs, guardianship, medical records
Connections- med risk assessment, signatures, CMCA supplement
Timelines Con't
- when a Med Rec should be completed
- when the CMCA and care plan should be shared with PCP
-when the CMCA and care plan should be updated
What is
- within 2 days of CMCA completion
-within 14 days of care plan completion
- annually (according to member birthdate, when member's needs change, and/or when there is a triggering event)
This is how you know if a member is approved for 1915i insurance, and for what dates
All notes should be in this format
Purpose, Intervention, Effectiveness
+ NEXT STEPS/Follow up or communication plan
The frequency in which care plans should be reviewed with the member/LG and how this is documented.
What is monthly? Care plan goals should be reviewed during monthly check ins and documented in task notes using Care Plan Review with Member/LG task.
Ongoing care management (post care plan completion) includes these things (monthly, quarterly, ongoing/as needed)
What is
monthly- care plan review with member (during monthly outreach); min. 1 billable contact per member
quarterly- face to face contact, progress towards goals (care plan update)
ongoing as needed- MDT meetings, CMCA updates, care plan updates 48 hour hospital f/u, 7 day hospital f/u, 1915i tasks, medical need f/u, provider contact, service referral, nurse consult, nurse referral, pharmacy consult, pre and post storm, clinical consultation
5 things a care plan must include (according to NCQA factors)
- specific to members situation and needs (goals should align with needs identified in the CMCA) (Factor 1)
-prioritized goals (set by member/LG) (Factor 1)
-target dates (staggered and agreed on by member/LG) (Factor 1)
-self management goals member/LG agrees to (Factor 4)
-barriers specific to that need and goal (factor 2)
Services for IDD only population
What is
ITS, IPS, Community Transition, Respite (under 18)
CLS, SE, Respite (includes adults)
What components must a note include to be billable (and not result in billing errors)
What is
current TCM auth with Trillium
TCM consent obtained (in task report)
contact established with member, LG, POA parent of minor
contact type must be phone, in person, video conference
1 primary dx with onset date prior to month of task
task is for only one date (not multiple dates or different dates in details vs. outreach log)- task date must be the actual date of the billable contact
The frequency in which progress towards goals should be updated and how this is documented.
What is quarterly, at minimum; based on target dates; for any triggering event., and documented in the Goal Items Status tab in the plan builder.
What should be included in a SNOW ticket email update?
What is
detailed information (facts only), answers to specific questions, what steps have been taken to address the problem/issue
11 Factors addressed in CMCA and Supplement
1- assessment of health status
2-documentation of clinical history
3-assessment of ADLs
4-assessment of BH status
5- assessment of SDOH
6- Evaluation of cultural and linguistic needs
7-Evaluation of visual and hearing needs
8- Evaluation of caregiver resources
9- Evaluation of available benefits
10- Evaluation of community resources
11- Assessment of life planning activities
Steps for requesting authorization for a 1915i service.
What is:
Add service code, provider, and units to care plan
upload care plan with signatures from CM, member/LG, and provider to TBS
Submit TAR (smartsheet form with correct dates and units)
When the CMCA task is entered
When the care plan task is entered
What is
CMCA- when you finalize the CMCA
Care plan- when plan is approved, you're uploading signatures, and publishing
For each identified need, the Goal, Intervention, Service, and Provider should reflect this.
What is the appropriate service and provider who is addressing that need and working on that goal with the member OR how the CM will assist the member with it (ie. linking/referring to a service/provider/community resource). ** TCM goals should not be clinical as it is not a clinical service.
Member Journey- Required tasks (in order) for all members
TCM Consent, CM Engagement, Case Referral, Record Review, Care Management (initial contact by CM), Care Management (contacts before CMCA is finalized), CMCA, [CMCA auto-generated tasks], Med Rec, Med Risk Assessment, Care plan review, MDT Coordination with Member/LRP, Care plan
Final 2 requirements for ongoing care management (factors 3 & 5)
- Follow up and Communication plan with members (The plan for follow-up should be commensurate with the “timebound” period/target dates of the goal(s).)
- Assessment of progress (Documentation of the member’s progress towards goals.)
1915i services that require a TAR be submitted for prior authorization
What are CLS, Respite, Community Transition, SE (IDD)
Tasks that populate the KPI dashboards
What are
TCM Consent, Case Referral, Record Review, CMCA, Care Plan, Med Rec., billable contacts