Care Plans
The kind of goals that should be in a care plan.
What are: SMART goals?
Specific, Measurable, Achievable, Realistic/Relevant, Time-bound
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
Timelines:
These two things are due within 2 business days of assignment
This is due within 30 days of assignment
What are:
record review & initial outreach (1st attempt)
CMCA (& Med Rec)
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 (examples) and these documents are uploaded in Connections (what & where)
What is:
TBS- any clinical docs, guardianship/legal docs, medical records, 1915i approval letter, CMCA, and care plan w/signatures (in clinical docs tab)
Connections- med risk assessment (in med rec task) & signatures (in plan builder attachments)
Timelines-
- when the care plan is due
- when the CMCA and care plan should be shared with PCP (sharing clinical documents)
-when the CMCA and care plan should be renewed
What is:
- within 30 days of finalized CMCA
-within 14 days of CMCA and care plan completion (each)
- for all: annually, according to member birthdate
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
Signature + Credentials
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 tasks (post care plan completion) include these things (monthly, quarterly, ongoing/as needed)
What is:
monthly- care plan review task (during monthly outreach); min. 1 billable contact per member, health promotions campaign, 1915i monitoring (if applicable)
quarterly- face to face contact, update progress towards goals, (Goal Item Status & care plan update task), MDTs, face to face 1915i monitoring (if applicable)
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
DOUBLE JEOPARDY!! 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/TBI population
What is:
MH/SU- ITS, IPS, Community Transition, Respite (under 18)
IDD- CLS, SE, Community Transition, Respite (includes adults)
DOUBLE JEOPARDY!! These things are required to bill TCM services & prevent billing errors. (Billable checklist)
What is:
current TCM auth with Trillium
TCM consent obtained (in task report)
contact established with member, LG, POA, or 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.,
Documented in the Goal Items Status tab in the plan builder.
DOUBLE JEOPARDY!! Medication Reconciliation Step Actions- incl. when to assign to pharmacy team
What is:
complete medication list form (in med rec task),
(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
11 Assessment Factors addressed in CMCA (extra 100 points for listing the 12th factor)
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
12 - Initiation of the assessment (CMCA) within 30 calendar days of identification and finalizing within 60 calendar days of identification.
DOUBLE JEOPARDY!! Steps for requesting authorization for a 1915i service (after 1915i insurance has been approved).
What is:
-Add service code, provider, and units to care plan
-upload CMCA and care plan with signatures from CM, member/LG, and provider to TBS clinical docs
-Submit TAR (smartsheet form with correct dates, units, provider and location)
When the Care Management Comprehensive Assessment task is entered
When the Care Plan task is entered
What is:
CMCA- on the same date you finalize the CMCA
Care plan- on the same date you publish the plan (with signatures uploaded)
DOUBLE JEOPARDY!! For each Goal, the selected 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.
DOUBLE JEOPARDY!! 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)
[CMCA auto-generated tasks]
Sharing Clinical Docs
Med Rec (to incl. med risk assessment)
Care plan review
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 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/TBI)
Tasks to complete for the UTR process
What are:
After 3 UTR attempts - on the 3rd unsuccessful outreach attempt, log a “Unable to Reach (UTR) Letter”
CM will submit UTR Letter via Letters / Document Mail Out Request Form to have it sent to member/legal guardian.
Complete and Send “Provider/Referring Agency UTR Notification Letter”
Upload the Provider/Referring Agency UTR Notification Letter to the Unable to Reach (UTR) Letter Task
Wait 10 calendar days on a response from the member/LRP. If no response, log a “Contact Member/LRP” task. In the task, identify the dates you were unable to reach the member/LRP, and date letter was mailed with no successful response.
Add the member’s information to the SmartSheet “Unable to Reach Log-BH RCT”
Complete Care Needs Screening Process for UTR. (SAG-section 5a)
Complete CNS in Member assessment widget and enter the “Care Needs Screening” task
Prior to member being end-dated from caseload, please ensure to staff with your direct supervisor, as they must review and end date the CM in the Connections system.