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 Med Rec task, (if score of 6 or higher- present to clinical staffing; if less than 6 complete task),
document score in med rec task
Timelines:
These are due within 2 business days of assignment
These are due within 30 days of assignment
This is due within 60 days of assignment
What are:
record review, initial outreach (1st attempt)
CMCA, Supplement (& Med Rec)
Care plan published w/ signatures uploaded
What step should be completed before submitting 1915i assessment to process Smartsheet
What is: Send to supervisor for approval via email
When notes are due
What is: within 2 business days
Before you submit a plan for audit, you should do these 3 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
These documents are uploaded in TBS and these documents are uploaded in Connections (what & where)
What is:
TBS- any clinical docs, guardianship, medical records (in clinical docs tab)
Connections- med risk assessment (in med rec task), signatures & CMCA supplement (in plan builder
Timelines Con't
- when a Med Rec should be completed
- when the CMCA and care plan should be shared with PCP (sharing clinical documents)
-when the CMCA and care plan should be updated
What is:
- within 2 days of CMCA completion
-within 14 days of CMCA and care plan completion (each)
- for all: 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
What is: TBS insurance tab
All notes should be in this format
What is: P.I.E. (+f/u)
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 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 review or update)
ongoing as needed- MDT meetings, CMCA & care plan updates for triggering events, 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
7 things a care plan must include (according to Care Management- Ongoing Management 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)
-communication plan (factor 3)
-progress towards goals (factor 5)
Services for MH/SU population
Services for IDD only population
What is:
MH/SU- ITS, IPS, Community Transition, Respite (under 18)
IDD- 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.,
(BONUS)- and documented in the Goal Items Status tab in the plan builder.
The task that must be completed within 14 days of completing the CMCA and 14 days of completing the care plan.
What is:
Sharing Clinical Documents
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 & upload the supplement
Care plan- when plan is approved, you've uploaded signatures, and published the plan
For each Goal, the Intervention should correlate with the ____ & _____.
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).
** BONUS: TCM goals should not be clinical as it is not a clinical service.
Member Journey- Required tasks (in order) for all members (think of New Assignment Checklist)
TCM Consent (triage),
Case Referral (CMS),
Record Review,
Care Management-billable (initial contact by CM),
Care Management (contacts before CMCA is finalized),
CMCA (once CMCA is finalized and supplement is uploaded),
[CMCA auto-generated tasks],
Med Rec (to incl. med risk assessment),
Sharing Clinical Docs
Care plan review,
MDT Coordination with Member/LRP,
Care plan
Sharing Clinical Docs
List at least 5 triggering events, what steps you take and in what timeframe
Inpatient hospitalization for any reason
Two emergency department visits since the last care management comprehensive assessment (including reassessment)
An involuntary treatment episode
Use of behavioral health crisis services
Arrest or other involvement with law enforcement/the criminal justice system, including the Division of Juvenile Justice
Becoming pregnant and/or giving birth
A change in member circumstances that requires an increased need for care, a decreased need for care, transition into or out of an institution, or loss of a parent/caregiver/legally responsible person/guardian, or any other circumstance the plan deems to be a change in circumstance
Loss of housing
Change in foster care placement or living arrangement (including aging out of the child welfare system)
Update CMCA & supplement within 30 days (and share with PCP/care team)
Update care plan based on CMCA updates (and share with care team)
1915i services that require a prior authorization
What are:
CLS,
Respite,
Community Transition,
SE (IDD)
Tasks to complete for the UTR process
What are:
enter "contact member/LRP" tasks for any unsuccessful outreach attempts and label them as "1st, 2nd, 3rd, attempt"
On 3rd unsuccessful attempts, log "Unable to Reach Letter" task and complete SS form for letter to be sent
Wait 10 calendar days on a response. If no response, log a "contact member/LRP" task and identify the dates of outreach attempts & the date the letter was mailed with no response.
Add member to "UTR LOG"