What's Your Next Move?
Member says: "I use Walgreens."
What's Your Next Move?
Ask what they like about Walgreens before moving on.
You identify financial barriers during the assessment, but the goal note only discusses blood sugar management.
What issue could this create?
The documented need and goal are not aligned.
On the previous call, you helped schedule a PCP appointment. At the next outreach, you do not ask whether the member attended.
What important follow-up was missed?
Evaluating the outcome of the appointment and documenting progress toward the goal.
Documentation says "member educated on hypertension."
Would this be considered strong documentation?
No. Documentation should include what was taught and how understanding was assessed.
OML Medication: Lisinopril 10 mg PO daily
Is this documentation correct?
No
Correct documentation:
Lisinopril 10 mg
Take 1 tablet by mouth daily
Member says: My pharmacy already delivers.
What's Your Next Move?
Explore whether they have any refill, medication, or pharmacy challenges.
The member's goal is to recognize symptoms of heart disease. The action plan tells the member to call for transportation benefits.
What's wrong with this action plan?
The action plan does not support the goal being addressed.
A member did not meet the exercise goal because of a recent injury, but the same intervention is copied forward into the next care plan.
What should have been done instead?
Adjust the goal, barriers, and interventions to match the member's current situation.
A member mentions food insecurity, but the conversation quickly moves to medications and never returns to food needs.
Would this be considered as the need addressed?
No. The need should be explored and addressed with interventions based on clinical assessment.
The member states: "I don't have my medications with me. Can we do that another day?"
The nurse documents the member did not have medications available and a plan for next CM to review on subsequent calls.
Is this an acceptable outcome?
Yes, as long as the member-driven reason is documented.
Member says: I tried mail order before.
What's Your Next Move?
Ask what happened before assuming they're not interested.
A member's memory concerns are documented in the AOF note's current status. The interventions include education on liquid diets and blood sugar management.
What issue might this create?
The interventions do not address the identified need.
A referral to Social Services was made last quarter. During today's review, no outcome from that referral is discussed.
Why is this a problem?
Care managers are expected to follow up on referral outcomes and document the results.
The barrier selected is "signs and symptoms," and the active intervention(s) focus only on community benefits.
What should be reconsidered?
The barrier should align with the member's actual challenge and interventions.
ICP Note states: "Medication review completed."
OML shows Metformin, Lisinopril, and Atorvastatin, but none were discussed during the call or updated.
Is this documentation correct?
No. A medication review requires discussion and verification with the member, not simply documenting that it was completed.
Tip: if member driven reason occurs and the CM is unable to complete review of all medications, Update medications reviewed, add a member driven reason and follow up plan for next call.
Member says: I'm good.
What's Your Next Move?
Ask one more discovery question.
The member's goal is managing diabetes. The action plan focuses entirely on renting an electric scooter.
What should the care manager reconsider?
Whether the interventions relate directly to the goal.
A member reports difficulty getting to follow-up appointments after discharge. The only intervention provided is a transportation phone number.
What stronger intervention could be offered?
Care coordination or direct assistance connecting the member to transportation resources.
The barrier says a member lacks knowledge about hypertension symptoms, with an active intervention related to Go365 and medication refills.
What should be reconsidered?
Providing active intervention(s) that directly addresses the identified barrier.
OML Medication: Ibuprofen Take 2 tablets or caplets every 6 hours for pain level 4 or above.
What is missing?
Medication Dosage
Ibuprofen 200mg Take 2 tablets or caplets every 6 hours for pain level 4 or above
Member says: I don't need that.
What's Your Next Move?
Find out why they feel their current setup is working.
A member reports recently stopping a medication because of side effects.
The nurse documents the medication as verified but does not explore the reason.
What additional action should occur?
The nurse should assess the issue and determine whether provider follow-up is needed.
The member reports biggest obstacle is remembering medications. The documented interventions focus on diet and exercise.
What opportunity was missed?
Providing active intervention(s) aimed at medication adherence and memory support.
Albuterol Sulfate 90 mcg/actuation inhalation aerosol
2 puffs by mouth as needed for shortness of breath
What is missing?
INHALE TWO PUFFS EVERY 4-6 HOURS AS NEEDED
SHORTNESS OF BREATH/WHEEZING
Member says: I don't need that.
What's Your Next Move?
Find out why they feel their current setup is working.
A Post Discharge survey is submitted at 94% completion because one question was skipped.
Would the survey be considered complete?
No, post discharge survey should be completed at 100% for compliance.
TIP: PDC survey documentation should align with what's in the ICP notes.
Member reports taking NovoLog (insulin aspart) 100 units/mL with meals and at bedtime based on a sliding scale and her blood sugar level at that time.
How should the nurse document this in OML?
NovoLog (insulin aspart) 100 units/mL
INJECT UNIT DOSAGE UNDER SKIN AS DIRECTED PER SLIDING SCALE BEFORE MEALS AND AT BEDTIME
Member says: My daughter helps me manage my medicines.
What's Your Next Move?
Discuss how delivery may help reduce caregiver burden.
Action Plan: "Member will call PCP."
What should be reconsidered?
No. The action plan lacks specific details and measurable next steps.
Compliant Example: Member will call PCP to schedule and complete the annual wellness visit by next call.
Member recently left the hospital.
What's Your Next MOP Move?
Talk about medication continuity during recovery.
Member says: The folks at the pharmacy know me. I enjoy seeing them.
What's Your Next Move?
That's wonderful. Having those relationships is important. Besides the social aspect, how is managing your medications working for you?
Redirect the conversation back to medication management needs.
Member says: Going to the pharmacy is the only time I really get out of the house.
What's Your Next Move?
I completely understand. Some members feel the same way. Would it be helpful to have some medications delivered while still keeping those pharmacy visits for the things you enjoy picking up yourself?