CC4C Care Management Standardized Plan

Transcription

1 The Care Crdinatin fr Children (CC4C) utlines methds and standards fr CC4C Care Managers t fllw, wrking in cllabratin with CCNC Medical Hmes and CCNC CMs, t achieve ur jint gal t imprve quality f care while cntaining csts. WHAT IS CARE MANAGEMENT? Care management is a cllabrative set f interventins and activities that address the health care and preventive service needs f a ppulatin t prmte quality, cst effective care. Care management is utcme-fcused and mnitrs the ppulatin and service delivery system using data. Care management prgrams apply systems and infrmatin t imprve care and assist recipients and their supprt systems t becme engaged in a cllabrative prcess designed t manage medical/scial/behaviral health cnditins mre effectively. When an individual reaches the ptimum level f wellness and functinal capability, everyne benefits: the individuals being served, their supprt systems, the health care delivery systems and the varius reimbursement surces. Care management serves as a means fr achieving client wellness and autnmy thrugh advcacy, cmmunicatin, educatin, identificatin and use f cmmunity resurces. (Adapted frm CMSA, 2010) 1. THE FUNCTIONS OF CARE MANAGEMENT (CM) INCLUDE: Access t and systematic use f data t include IC Reprts, Prvider Prtal, Pharmacy Hme, CMIS, t target recipients and prviders fr utreach, educatin, and interventin Mnitring system access t care, services, and treatment including linkage t medical hme Addressing the ttal individual, inclusive f medical, psychscial, behaviral, and spiritual needs. Invlvement f the recipient and their supprt systems (i.e. caregiver, family, etc.) in the decisin-making prcess Use f a patient-centric, cllabrative partnership apprach t assist the recipient with imprved self-care Utilizatin f prven prcesses t measure a recipient s understanding and acceptance f the prpsed plans, his/her willingness t change, and his/her supprt t maintain health behavir change Expanding the interdisciplinary team in planning care fr individuals Cmmunicating and crdinating with all prviders and members f the care team, in an effrt t minimize fragmented care Navigating transitins f care Mnitring quality and effectiveness f interventins t the ppulatin by setting bth lng term and shrt term specific, measurable gals. Advcating fr recipients and supprting prviders t ensure delivery f apprpriate, evidence based care Supprting the medical hme thrugh educatin and utreach t recipients & prviders Supprting Practice-Based Quality Imprvement activities by: (1) assisting families in accessing services based n Care Alerts and/r anticipating the child s health care needs based n best practice; and (2) supprting CCNC/CHIPRA Staff in their effrts t educate, supprt and mnitr prviders regarding evidence-based care fr best practice/natinal Standards f Care. (Adapted frm CMSA, 2010) 1 1 Care Management Sciety f America, Standards f Practice fr Case Management. Little Rck, Arkansas CC4C CM : Effective February 18, 2013 Page 1

2 WHY IS STANDARDIZATION IMPORTANT AND HOW ARE CM ACTIVITIES MEASURED? Cmmunity Care f Nrth Carlina (CCNC) netwrks, in partnership with lcal health departments, share respnsibility fr the delivery f at risk ppulatin care management services fr children birth t 5 that will imprve quality f care while cntaining csts. In rder t measure the impact/effectiveness f care management (CM), there must be standards f dcumentatin acrss all health departments prviding CC4C CM services that are cnsistent with CCNC dcumentatin standards. Fr the purpse f measuring utcmes, patients are cnsidered care managed if their case status is Heavy r Medium during the reprting perid. Patients wh fall within the identified chrt are fllwed fr CC4C prgram evaluatin / reprting based n cntractually-identified perfrmance metrics. Data is analyzed fr meaningful trends in quality, cst, utilizatin and CM activity. Patients being actively care managed (heavy/medium case statuses) shuld have clear dcumentatin in the CCNC Case Management Infrmatin System (CMIS) that includes: Cmprehensive Health Assessment (CHA) Life Skills Prgressin (LSP) Assessment (as apprpriate) Cnditins and/r Prblems Tasks / Interventins Medicatin Management (in Med Mdule) (as apprpriate) Gals Patient Centered & Measurable Other Care Management Activities Recrded WHO ARE OUR PRIORITY POPULATIONS FOR CC4C CM? CCNC and DPH are wrking dynamically with the netwrks and health departments t establish pririties that identify recipients wh are mst likely t benefit frm care management interventins. This has been, and will cntinue t be, a prcess f revisiting and refining ur infrmatin supprt, ur prcesses, and ur interventins as we develp new tls and resurces (e.g. analytics) t better manage ur ppulatin and priritize ur care management activities. CC4C care management staff are expected t target these pririty ppulatins in an effrt t make an impact n the quality and cst f care. Transitinal Care Pririty As CC4C staff are trained in the transitinal care mdel, they will be expected t wrk in clse cllabratin with CCNC care managers t serve these impactable families at a highly impactable mment. Children in the hspital with a Transitinal Care (TC) Pririty Indicatr are a PRIORITY POPULATION and all are expected t be apprached fr transitinal care. CCNC evaluative data has determined that this ppulatin benefits mst frm transitinal care by preventing readmits. NICU babies and ther infants/children wh are transitining frm the hspital back t the cmmunity als benefit frm transitinal care services. CCNC Pririty Indicatr High risk/high cst patients are a PRIORITY POPULATION fr receiving CC4C care management. CCNC evaluative data finds that this ppulatin benefits frm care management. The CCNC Pririty Indicatr pints t the fllwing pririty ppulatins: Pririty Ppulatin List (PPL) The CC4C Pririty Ppulatin List cntains the names f children wh have been flagged fr pririty fllw-up based n whether they have had mre ptentially preventable hspital services relative t ther children in their clinical risk grup (CRG). These patients are nn-dual enrllees (ABD and Nn-ABD) wh have incurred mre in hspital cst (ED and inpatient admissins/readmissins) in the past year than wuld be expected given their CRG. It is based n Tre Slutins risk-adjusted data methdlgy that indicates their hspital cst is abve expected and ptentially preventable with care management interventin. CC4C CM : Effective February 18, 2013 Page 2

3 Pririty Duals Althugh it is rare fr children ages birth t 5 t be dually-eligible fr bth Medicaid and Medicare (n average ~12 ut f 336,000 Medicaid-eligible children in this age grup), these children represent a high risk and high cst grup. Since risk stratified data is nt available, claims are evaluated using CCNC methdlgy and patients meeting all 3 f the fllwing criteria receive the pririty indicatr: 1. One r mre inpatient admissins within the past 6 mnths 2. Tw r mre ED visits within the past 6 mnths 3. One r mre key target cnditins: CHF, DM, IVD, Asthma r COPD. Real-Time Referrals are a PRIORITY as we seek t meet the needs f CCNC Prviders/Practices and cmmunity partners such as: Patients referred frm Primary Care Prviders and CCNC Care Managers (including CCNC CMs frm the Child Health Accuntable Care Cllabrative r CHACC Prgram) Hspitals (including Nenatal Intensive Care Unit, Pediatric Intensive Care Unit, Other Inpatient Referrals and Emergency Department Referrals) Referrals frm ther cmmunity prviders e.g. OBCM; WIC; CDSA; LME/MCO; CAP; etc. CCNC Call Center Referral Categries: *Ptential Safety Issue *Ptential ED Utilizatin Issue *Ptential Care Management Need as Reprted by Patient *Autmatic Referrals sent in Respnse t Patient Survey Respnses *Other Identified Needs Additinal Data Reprts [e.g. Current Hspital Visit r ADT (Admissins, Discharges, Transfers)] ; Inpatient Visit; ED Visit; and S1 Reprts) may als pint t CM pprtunities fr identifying high risk/high cst patients and supprting the medical hme. The S1 Reprt specifically can be used t identify children in fster care, including thse wh are nt enrlled in a CA II Medical Hme. Care Alerts: CC4C CMs are expected t utilize Care Alerts n their patients t identify pprtunities fr clinical utreach and quality imprvement with practices and patients. [Nte: Be aware that Care Alerts are satisfied based n receipt f claims that demnstrate that a service r need has been addressed. If yu fllw-up n a Care Alert and the need has been addressed, dcument this infrmatin in a task s anyne reviewing the recrd will have this updated infrmatin]. Expectatins fr Ppulatin Management All hspitalized patients with the CCNC Transitinal Care Pririty OR CCNC Pririty Indicatr are expected t be apprached fr transitinal care. If the CC4C Care Manager is nt a part f the CC4C Transitinal Care Pilt Implementatin Prject and/r has nt yet been riented and trained t prvide this service, then they shuld cllabrate with CCNC CMs t address the TC needs f their Medicaid CA II patients. This cmmunicatin will als prmte crdinatin f care and prevent duplicatin f effrts. All CCNC Pririty patients (PPL, Pririty Duals) are expected t be evaluated fr services within 3 mnths f being identified. All referrals frm prviders and CCNC/CC4C/OB-CM clleagues are expected t be evaluated fr services within 3 business days f referral. The bjective is t quickly evaluate the patients cming in the dr, assign them t a CM and priritize fllw-up based n patient needs. CC4C CM : Effective February 18, 2013 Page 3

4 PRIORITIZATION STRATEGIES FOR OUTREACH AND ASSESSMENT OF CCNC PRIORITY PATIENTS In general, the greatest benefit fr care management utreach is realized amng patients with the greatest abve expected hspital csts. The Pririty Patient List is pre-srted accrding t this dllar amunt. Other cnsideratins fr utreach priritizatin wuld be: * Newly enrlled in CCNC/Carlina Access II * Inactive care management status * Light r deferred care management status (including thse deferred fr being well-linked ), if mst recent assessment r date f deferral was > 90 days ag [Assess CCNC data and child s recent medical histry (based n parent cntact) fr ptentially preventable activity (hspitalizatin/ed use) since last assessment. This may include activity ccurring in last 90 days fr claims nt yet dcumented in Prvider Prtal]. * Any additinal indicatin f active needs, such as current r recent hspitalizatin r ED visit (e.g. ptentially preventable activity in the past 6 mnths), r prvider referral UTILIZE A TEAM APPROACH FOR MANAGING THE PRIORITY POPULATIONS Building a fully integrated system f care fr children birth t five years f age is the gal f the CCNC/CC4C cllabrative care mdel. The benefits f a crdinated apprach include increased family satisfactin, increased CM efficiency, and decreased duplicatin f effrt. Utilize an interdisciplinary team t assure that care management needs are met that includes netwrk resurces, ther health department and cmmunity resurces, and the care team at the medical hme [especially invlvement f the Primary Care Prvider (PCP)] as fllws: Patients Receiving Care Management Services Examples f Resurces t Ptentially Engage &/r Cllabrate With* OBCM-identified pregnant wmen whse children are a part f OBCMs wrk cllabratively with CC4C CMs t assure a smth the target ppulatin fr CC4C services. transitin frm OBCM t CC4C services fr the family. Infants transitining frm NICU/PICU r hspital back t OBCM; EI; CCNC TCMs in Hspital Setting; CHACC; CCNC CMs cmmunity. /Medical Hme Team. Children birth t < 5 wh are identified as pririty r target CCNC & CC4C CMs - Wrk cllabratively t assure that all the ppulatins fr CC4C and/r CCNC care management services child s health care needs are met withut duplicatin f effrt. Infants/Tddlers < 3 Years f Age with Develpmental Delay r Infant/Tddler Prgram if child < 3 y.. & has develpmental Established Cnditin Likely t Cause Develpmental Delay delay r established cnditin that is very likely t cause a develpmental delay. Online I-TP Referral Frm psted in CMIS (Tls -> Patient Referrals). [ Preschl Children 3 t 5 years f Age with Develpmental Preschl Exceptinal Children s Prgram - Referral frms Delays (ASQ/PEDS) r Psitive MCHAT r Autism Surveillance available frm Lcal Exceptinal Children Prgrams. with 2+ risk factrs [ ] Children expsed t a txic stress envirnment r living in LME/MCO; DSS Child Prtective and Fster Care Services; fster care Trauma-Fcused Cgnitive Behaviral Therapists [ Children/families with behaviral health issues f cncern LME/MCO (fr assistance in chsing an apprpriate behaviral health prvider); CCNC Netwrk Behaviral Health Crdinatrs can assist care managers wh need assistance lcating r linking t an apprpriate cmmunity resurce. Children prescribed anti-psychtic medicatins CCNC Netwrk Pharmacist/ A+ Kids Prgram Children wh are disabled r medically fragile and wh are at Cmmunity Alternative r CAP Prgrams - Prvide Case risk f being placed in an institutin Management, In-hme Aide/Nursing Services, Respite Care, Hme Mbility Aids based n what is required. Children with Palliative Care Indicatr (PC) CCNC Netwrk Palliative Care Resurces. *Anther ptential resurce in sme cmmunities are lcal hme visiting prgrams (e.g. Nurse Family Partnership; Healthy Families America; Parents as Teachers; and Early Head Start/Hme-Based Optin). CC4C CM : Effective February 18, 2013 Page 4

5 WHAT IS EXPECTED OF THE CC4C CARE MANAGER? CC4C CMs are vital participants in the care team wh empwer families/children served t understand and access quality, crdinated, effective health care. CC4C care managers, in cllabratin with CCNC netwrk staff and certain partnering agencies, prvide a variety f services in the frm f ppulatin management and direct care management as described abve. CC4C care managers are expected t identify families/children t target fr care management services based n CC4C Pririty Ppulatins (see pages 2-3). In an effrt t meet the child s cmprehensive health needs thrugh cmmunicatin, interventins, and available resurces and t prmte quality cst effective care, care managers are t implement a cllabrative prcess f: Assessment Planning Facilitatin Crdinatin f Care Educatin Advcacy Evaluatin (Adapted frm CMSA, 2010) 1 DOCUMENTATION IN CASE MANAGEMENT INFORMATION SYSTEM (CMIS) CMIS is a secure, web-based system fr the management f its enrllees that is a user-built, patient-centric, electrnic recrd f care management activities. CMIS cntains standardized health assessments, care plans, screening tls, disease management, health caching mdules, and wrkflw management features ALL care management activities (tasks), interventins, prgress tward gals, etc., are dcumented in CMIS. CCNC/Netwrk and DPH Leadership will use CMIS t assess the impact f care management. Therefre, it is imperative that: care managers utilize the standardized prcesses defined in this plan and within the CMIS definitins dcuments t dcument their invlvement with the individuals receiving care management services in CMIS; the dcumentatin be cnsistent acrss CCNC Netwrks, Lcal Health Department CC4C & Pregnancy Care Management staff and ther prgrams using CMIS fr care management dcumentatin. CMIS is fr reprting bth individual and ppulatin level infrmatin CMIS enables the CC4C care manager t assess, plan, implement, and evaluate patient care management thrugh use f the fllwing capabilities in CMIS: Accessing Claims Data and Other Clinical and Patient-Centric Data Case Assignment Patient Assessment and Care Planning Medicatin Management Secure Messaging System 1 Case Management Sciety f America, Standards f Practice fr Case Management. Little Rck, Arkansas CC4C CM : Effective February 18, 2013 Page 5

6 ASSESSMENT During a brief/initial evaluatin perid the CC4C care manager shuld view the fllwing infrmatin, if available: prvider prtal infrmatin patient snapsht previus Cmprehensive Health Assessments (CHAs) hspital data The gal is t btain enugh infrmatin t determine if yu have the ptential t impact the patient; and then t initiate cntact with the family. All infrmatin gathered shuld be dcumented in the CHA. The next step is patient engagement using Mtivatinal Interviewing (MI) techniques. If yu need additinal supprt in the use f MI techniques, wrk with yur health department MI Champin. Once patient engagement is secured (and yu have assigned the CC4C care manager and prgram), begin t ppulate the CHA with infrmatin gathered thrugh a mre cmprehensive assessment and dcument the activities utilizing patient tasks in CMIS. The CHA is a wrking dcument abut the patient s past and current medical, behaviral, and scial histry and shuld be updated n a regular basis as new infrmatin is btained. It serves as the patient s health recrd, allws the care manager t identify and pen cnditins, and stays with the patient as he r she mves frm ne area f the state t anther. Any CCNC r CC4C CMs shuld be able t review a CHA and feel secure that they are aware f pertinent medical infrmatin that will assist them in prviding services t the patient. In additin, fr specified target ppulatins, dcument a Life Skills Prgressin (LSP) Assessment initially (within the first tw cntacts). Fr thse with identified needs that the family is willing t wrk n, repeat the LSP every 6 mnths & upn clsure. [See Case Status Guidance n page 7 fr mre detailed LSP Assessment Guidance]. PLANNING & IMPLEMENTATION With the family, frmulate a patient-centered plan f care and establish measurable gals. Dcument the fllwing cmpnents f the plan in CMIS: Patient-Centric Gals Tasks and Interventins [Imprtant! Always leave an active recrd with a pending task t assure that yu have a reminder abut next step(s) fr each patient in yur caselad]. Fllw up / Mnitring Frequency Case Status (Level f Service Intensity) EVALUATION CC4C CMs are t perfrm regular case status and gal reviews (in CMIS) at a minimum f every 90 days, while the patient is being care managed at Heavy r Medium status. Gals shuld be specific and measurable, include bth lng term and shrt term gals related t their pririty risk r patient needs. CC4C CM : Effective February 18, 2013 Page 6

7 CASE STATUS DEFINITIONS Case Status defines the intensity level f care management needs fr THE PATIENT (CHILD) and must reflect direct service with the child (r his/her family). Activities nt directly related t a patient-centered interventin, e.g. attempted tasks related t engaging the patient, SHOULD NOT be cunted tward case status requirements. IMPORTANT! CC4C care managers are required t schedule a pending task fr all patients wh have an active case status f Heavy, Medium, Light r Pending. The pending task(s) shuld reflect planned activity t address the patient s needs. Dcumentatin shuld clearly explain why the patient is receiving care management and hw the planned activities will help t achieve the patientcentric gal(s) develped with the family. Dcumentatin Requirements Gals Tasks Intense Care Management - Heavy One r mre dcumented patientcentric gals related t their pririty risk r patient needs Ptential t impact quality, cst and/r utilizatin with family s engagement/willingness t participate. An initial Cmprehensive Health Assessment; update n nging basis. A Life Skills Prgressin initially (within first tw cntacts) fr specified target ppulatins. 2 Fr thse with identified needs that the family is willing t wrk n, repeat the LSP Assessment every 6 mnths & upn clsure. 3 The ASQ-3 Develpmental Screen is dne in cnjunctin with each LSP Assessment & the ASQ-3 scres are captured as a part f the Infant/Child prtin f the LSP Assessment. Evidencebased practice requires that the LSP Assessment be cnducted during a hme visit with rare exceptin. 4 T have the maximum impact, families wrking n LSP gals shuld be cntacted n at least a mnthly basis (Heavy r Medium Intensity Level) fr the first 6 mnths. These interim cntacts can be dne by phne r as a face-tface cntact in the cmmunity, practice r hme setting. After the first 6 mnths, CMs can assess the family s prgress & engagement, and select a case status based n that assessment. Case status and gals shuld be updated at a minimum f every 90 days. Intense Care Management Medium Ptential t impact quality, cst and/r utilizatin with family s engagement/willingness t participate. An initial Cmprehensive Health Assessment; update n nging basis. A Life Skills Prgressin initially (within first tw cntacts) fr specified target ppulatins. 2 Fr thse with identified needs that the family is willing t wrk n, repeat the LSP Assessment every 6 mnths & upn clsure. 3 The ASQ-3 Develpmental Screen is dne in cnjunctin with each LSP Assessment & the ASQ-3 scres are captured as a part f the Infant/Child prtin f the LSP Assessment. Evidencebased practice requires that the LSP Assessment be cnducted during a hme visit with rare exceptin. 4 T have the maximum impact, families wrking n LSP gals shuld be cntacted n at least a mnthly basis (Heavy r Medium Intensity Level) fr the first 6 mnths. These interim cntacts can be dne by phne r as a face-tface cntact in the cmmunity, practice r hme setting. After the first 6 mnths, CMs can assess the family s prgress & engagement, and select a case status based n that assessment. Case status and gals shuld be updated at a minimum f every 90 days. One r mre dcumented patientcentric gals related t their pririty risk r patient needs At least 1 dcumented and cmpleted task per week r 4 per mnth, at a minimum At least 1 dcumented and cmpleted task per mnth (nce every 30 days at a minimum). 2 Specified target ppulatins include all children referred fr r subsequently identified with txic stress expsure and ther children, as apprpriate, based n the prfessinal judgment f the care manager. This may include children nt identified as being expsed t txic stress, but wh have develpmental, scial r behaviral health issues f cncern. 3 Accrding t Linda Wllesen, authr f the Life Skills Prgressin: An Outcme and Interventin Planning Instrument fr Use with Families at Risk, the greatest impact n families frm wrking n LSP-related gals is realized within the first 6 mnths. Based n that knwledge, it is imprtant that we fllw these families fr a minimum f 6 mnths r lnger [until identified needs are met (LSP dmains hit target scres) r a specific deferral reasn results in clsure] in rder t have LSP Lngitudinal Outcmes that demnstrate the value f this cmpnent f CC4C services. 4 Rare exceptins include Cmmunity/Practice Encunter if HV impssible; Phne Call fr Clsing LSP if Hme Visit impssible (e.g. family mved away). CC4C CM : Effective February 18, 2013 Page 7

8 Dcumentatin Requirements Gals Tasks Care Management - Light (Patient Maintenance) Patient has been referred t an utside agency and CM mnitrs t assure that linkage ccurred. Maintenance f stable cnditins/prblems, and/r Ppulatin Management Services*, e.g., reslutin f health care access issue r mailings directed at prgram initiatives/preventin, etc. Use the CHA and/r Task Ntes, as apprpriate. Gal(s) may be dcumented as a part f a patient-centered care plan, as apprpriate, but is nt required. Specified target ppulatins fr receipt f the LSP shuld be fllwed based n the guidelines nted under Heavy r Medium Case Status & Ftntes (see previus page). N/A Minimum f 1 r mre dcumented tasks per year (but nt mre than 2 per quarter) *Nte: When bulk tasks are used t implement ppulatin management, CMIS recrds a task fr each patient. Care Management Pending Perid when staff is attempting t engage the patient N/A Perid when newly identified patients are being assessed t determine level f care management required. Pending Status shuld nt be used fr mre than 30 days* unless utreach effrts are clse t securing cntact and engagement. If n decisin regarding CM needs has been made within this time frame, the patient s status shuld be changed t deferred. N/A *Nte: Patients with extended hspital stays (e.g. NICU babies, severe trauma, etc.) may stay in pending status lnger than 30 days r status may be updated. CC4C CM : Effective February 18, 2013 Page 8

9 CARE MANAGEMENT DEFERRAL REASONS Fllwing patient assessment and/r a perid f prviding care management, it may be apprpriate t set status as deferred if ne f the fllwing reasns apply: Deferral Reasn Well-linked Identified Needs/Gals Have Been Met Unable t Cntact Unable t Set/Wrk Tward Gals in Care Plan N CM Needs Identified Based n Referral Criteria r Utilizatin Refused Services Des Nt Qualify fr CM at this Time PCP Recmmends Deferral Deceased Definitin Patient assessment reveals n care management needs at this time because patient is welllinked t medical hme and/r ther services. Identified needs/gals fr patient have been reslved as a result f CC4C CM activity. CM is n lnger prviding CM services. (One shuld select this reasn nly if CM services have been prvided previusly). At least 3 5 unsuccessful attempts t cntact are dcumented as ccurring at different times/different days/different ways. Cntact attempts fr Pririty Ppulatins shuld nt be limited t telephne calls. Strategies may include meeting the patient/family at a scheduled PCP visit, WIC/HD, r ther appintment; flagging a patient chart t refer t CC4C CM if patient cmes fr appintment; ding a hme visit; and letters/mailings. CM has made multiple attempts t help family set and wrk tward meeting gals in patient-centered plan f care withut success. User shuld select this after she/he has attempted t wrk with family n behalf f the child and has ntified PCP f circumstances resulting in deferral fr this reasn. (This is nt based n PCP request t defer). N identified CM needs at this time based n CC4C referral/screening criteria &/r utilizatin histry: Target ppulatins include children with special health care needs; in fster care; transitining frm NICU back t cmmunity; expsed t txic stress; referred by CCNC Netwrk staff r medical hme; and/r children identified thrugh Infrmatics Center Reprts with pririty given t children flagged n a Pririty Ppulatin List, children needing transitinal care OR children with any ther Pririty Indicatr. Patient evaluatin via data/chart review indicates patient is up t date n well child check-up AND patient has had < 2 ED visits in the last 6 mnths and/r < 2 inpatient admits in the last 6 mnths. Family verbalizes they d nt want CC4C CM services fr their patient/child at this time r they refuse referral fr linkage. Data review and/r assessment indicates patient des nt qualify fr CC4C CM services at this time due t age > 5, mved ut f state, r is living in a facility (i.e. institutin) r ther circumstance that prhibits the family frm setting gals. Patient is deferred at PCP s request/recmmendatin. Deceased CC4C CM : Effective February 18, 2013 Page 9

10 CCNC/CC4C TEAM AND TRANSITIONAL CARE MODEL / REAL-TIME INPATIENT REFERRALS [Effective date t be determined n a cunty by cunty, netwrk by netwrk basis based n CC4C CMs receipt f CCNC rientatin, CCNC Netwrk training and a validatin f required skills]. The CCNC transitinal care prgram cntinues t be a pririty apprach t finding impactable peple at a highly impactable mment. At the pint a CCNC CM encunters a patient in the hspital ther predictive factrs abut their risk f readmissin (certain medicatins, fragility, scial supprts, etc) are ging t vershadw the imprtance f any histrical claims indicatr. A primary gal f transitinal care is t prevent readmissins. Prmpt fllw-up pst hspital discharge (as defined belw) is required by CCNC/CC4C CMs as the patient transitins back t the cmmunity and a medical hme. KEY COMPONENTS OF THE TRANSITIONAL CARE MODEL Face-t-Face Family/Patient Encunters CCNC/CC4C Medicatin Management Patient Self-Management Ntebk / Patient Educatin Fllw-Up Calls and Cntact Pst-Discharge Fllw-Up with PCP r Specialist in a Timely Manner FACE TO FACE PATIENT ENCOUNTERS Hspital 5 Netwrks are expected t have embedded Care Managers in large-vlume hspitals t interact with the hspital team (Hspitalists, Discharge Planning, Pharmacy, Palliative Care, etc.) t facilitate ptimal hspital stay that includes discharge planning at the time f admissin. The assigned CCNC TCM shuld visit the patient/family at bedside t begin engagement, and cllabrate with the hspital care team t ensure that prcesses are in place fr a smth and timely discharge. Critical dcuments t secure are discharge instructins, a discharge medicatin list, discharge summary if available, and ther dcuments as applicable. Hme Visit The gal fr TC Pririty Patients and ther patients at high-risk fr a failed transitin is fr them t receive a hme visit within 3 days f discharge with the pririty interventin being medicatin management. Additinal hme visits and/r jint PCP visits are ften needed t facilitate ptimal care management. Practice and Cmmunity Encunters with the Patient/Family Althugh a hme visit is cnsidered the best methd f prviding a thrugh assessment f bth the patient/family and their hme envirnment, there are times when it may be mre apprpriate (r as a supplement t the hme visit) t have a face-t-face encunter with the patient/family in the cmmunity r at the prvider ffice. The parent/guardian shuld be instructed t bring all f the patient s medicatin bttles with them s that medicatin management can be initiated. 5 While the majrity f transitinal care patients are mving frm hspital t hme, patients transferring in and ut f ther facilities/living envirnments may benefit frm transitinal care as well. CC4C CM : Effective February 18, 2013 Page 10

11 CCNC/CC4C TEAM AND MEDICATION MANAGEMENT [Refer t CCNC/CC4C Team & Medicatin Management fr CC4C Patients sectin f this dcument]. PATIENT SELF-MANAGEMENT NOTEBOOK / FAMILY EDUCATION Self-Management Ntebk Prvide individualized family educatin and assist the family with implementatin f the Self-Management Ntebk fr their child, as apprpriate. This ntebk serves as a persnal health recrd fr the patient and a cmmunicatin tl with PCP, specialty prviders, and ther healthcare services t facilitate cntinuity f care. Dcument the verall cntent f educatin, (e.g. side-effects f meds and when t reprt), and include name(s) f CCNC/CC4C Patient Educatin tl(s), if used, alng with the family s respnse t teaching. Red Flags Prvide family educatin n red flags that culd indicate a cmplicatin r exacerbatin, requiring a call t the dctr, CM, r ther in-hme service prvider t prevent ptential ED visit/readmissin. Utilize Mtivatinal Interviewing techniques, teach-back, and ther evidence-based patient/family educatin strategies fr ptimal utcmes. FOLLOW-UP CALLS AND CONTACT Timely Fllw-up Ensure patient has a fllw-up appintment with PCP/specialists quickly after discharge. Assess fr ptential barriers t patient attending the appintment and assist with planning, transprtatin, etc. t facilitate cmpletin f appintment. Transitinal care fllw-up shuld cntinue fr a minimum f 30 days. DOCUMENTATION STANDARDS FOR TRANSITIONAL PATIENTS When dcumenting the Transitinal Care prcess, use apprpriate TC interventins/tasks. As yu cntinue t wrk thrugh the Transitinal Care Mdel, dcument the interventins named abve as yu accmplish them. The gal is t include all interventins named abve during the transitin perid. The transitinal perid nly applies t perid frm hspital admissin thrugh 30 days pst discharge. CC4C CM : Effective February 18, 2013 Page 11

12 CCNC/CC4C TEAM & MEDICATION MANAGEMENT FOR CC4C PATIENTS [Effective date t be determined n a cunty by cunty, netwrk by netwrk basis based n CC4C CMs receipt f CCNC rientatin, CCNC Netwrk training and a validatin f required skills]. The prcess f gathering, rganizing and sharing with cmmunity-based prviders, medicatin use infrmatin frm multiple surces (including the family, medical chart, prescriptin fill histry, and discharge instructins) in rder t identify and reslve urgent/emergent duplicatins, interactins, pssible adverse events, pr adherence r ther subptimal medicatin-taking behavir(s). In the CC4C Prgram, the CCNC and CC4C staff will wrk in clse cllabratin t accmplish this task t avid duplicatin f services, ensure the patient s needs are met, and t assure that apprpriately-qualified staff are carrying ut the varius tasks, as nted belw: A. MEDICATION LIST WHO: This task may be perfrmed by a Licensed Practical Nurse, nn-nurse CM (Care Manager), pharmacy technician, r ther persnnel with adequate skill cmpetency as determined by the Netwrk in cnjunctin with the CCNC Pharmacy Prgram. While an RN-CM can perfrm this task, the intent is fr ther staff t cmplete this step f the medicatin management interventin. WHAT: 1. Cmpile a set f medicatin lists by surce, including but nt limited t: *Discharge instructins frm hspital/facility, if applicable *PCP Chart/EHR *Fill Histry (Pharmacy Hme/CMIS) *Family Reprt (Nn-clinical CMs can write dwn the list per patient reprt, as it is a necessary part f the infrmatin the RN r Pharmacist will need t d the next step in the prcess. This is nt a Family/Caregiver Interview (see B. MEDICATION RECONCILIATION under WHAT belw). Specialist(s) Chart(s)/EHR(s) Hme Care-Based Service Prvider Retail Pharmacy 2. Hand ff list t RN-CM and/r Pharmacist fr Medicatin Recnciliatin and/r Medicatin Review. * = Mst imprtant medicatin list surces. B. MEDICATION RECONCILIATION [Fr patients being served by CC4C staff trained in Medicatin Management, this step must be cmpleted fr all patients being care managed at heavy r medium status, including TC patients]. WHO: Optimally, this interventin shuld be perfrmed by an RN with apprpriate clinical training and adequate skill cmpetency as determined by the Netwrk in cnjunctin with the CCNC Pharmacy Prgram. Netwrk Leadership may delegate this interventin t thse with prfessinal degrees and/r licensed prfessinals wh pssess apprpriate clinical training and adequate skill cmpetency (unless excluded by their scpe f practice as defined by their licensing entity). All medicatin recnciliatins perfrmed by a nn-rn must be apprved by the supervising RN r Netwrk Pharmacist. WHAT: Family and/r Caregiver Interview takes place in the hme, clinic, r via telephne, using the Medicatin Lists (as nted under A abve) t enhance drug use infrmatin gathering. At a minimum, this is the prcess f identifying duplicatins and/r discrepancies between the medicatins lists and ther surces (e.g. fill histry, family/caregiver interview, PCP chart) arising frm uncrdinated care r patient nn-adherence.. CC4C CM : Effective February 18, 2013 Page 12

13 C. MEDICATION REVIEW - COMPREHENSIVE WHO: Medicatin Review may be perfrmed by a Pharmacist r PCP. The CM shuld serve as a liaisn between PCP, pharmacist and patient/family as needed. WHAT: In-depth glbal review f the medicatin regimen and drug use histry t identify cmplex prblems. Review includes all aspects f medicatin management, including: cst-effective medicatins, duplicatins, side effects, cntraindicatins, interactins, allergies, adverse event identificatin, and evidence-based recmmendatins. Prcess is initiated by referral frm CM r PCP (and is nt limited slely t transitinal care patients).. CC4C CM : Effective February 18, 2013 Page 13

14 ACRONYMS USED IN CC4C CARE MANAGEMENT STANDARDIZED PLAN ABD: ADT: ASQ: CA: CC4C : CCNC: CAP: CDSA: CHA: CHACC: CHF: CHIPRA: CM: CMIS: CMSA: COPD: CRG: DM: DSS: Duals: ED: EHR: EI: HV: IC: IP: I/TP: IVD: LHD: LME: LSP: MCO: MI: N/A: OBCM: NICU: PC: PCP: PEDS: PICU: PPL: TC: TCM: WIC: Aged Blind Disabled (Medicaid Eligibility Categry) Admissins, Discharges, Transfers Ages and Stages Questinnaire (Develpmental Screening Tl) Carlina Access Care Crdinatin fr Children Cmmunity Care f Nrth Carlina Cmmunity Alternatives Prgram Children s Develpmental Service Agency Cmprehensive Health Assessment Child Health Accuntable Care Cllabrative Cngestive Heart Failure Child Health Insurance Prgram Reauthrizatin Act Care Manager Care Management Infrmatin System Case Management Sciety f America Chrnic Obstructive Pulmnary Disease Clinical Risk Grup Diabetes Mellitus Department f Scial Services Eligible fr Medicaid and Medicare Emergency Department Electrnic Health Recrd Early Interventin Hme Visit Infrmatics Center Inpatient Infant/Tddler Prgram Ischemic Vascular Disease Lcal Health Department Lcal Management Entity Life Skills Prgressin Assessment Managed Care Organizatin Mtivatinal Interviewing Nt Applicable Pregnancy Care Management Nenatal Intensive Care Unit Palliative Care Primary Care Prvider Develpmental Screening Tl Pediatric Intensive Care Unit Pririty Ppulatin List Transitinal Care Transitinal Care Manager Wmen, Infants and Children (Supplemental Fd Prgram) CC4C CM : Effective February 18, 2013 Page 14