Standardization & Reporting Why is standardization important? Community Care of North Carolina (CCNC) networks, in partnership with local health departments, share responsibility for the delivery of at risk population care management services for children ages birth to 5 that will improve quality of care while containing costs. In order to measure the impact/effectiveness of care management (CM), there must be standards of documentation across all health departments providing CC4C care management services that is consistent with CCNC documentation standards. What is expected of the Care Manager and how are CM activities measured? The Care Managers in each CCNC network and certain partnering agencies, including health departments providing CC4C services, provide a variety of services in the form of population management and direct care management. CCNC and DPH are working dynamically with networks and health departments to establish priorities that identify recipients who are most likely to benefit from care management interventions. Once identified, recipients who agree to participate should have clear documentation of a comprehensive health assessment (CHA), conditions/problems, interventions, goals and other care management activities recorded in the Care Management Information System (CMIS). For the purpose of measuring care management outcomes, patients are considered care managed if their CM status is Heavy or Medium during the reporting period. CMIS documentation for these patients should also include: one or more documented goals a comprehensive health assessment (documented initially; updated with relevant information on an ongoing basis; and reviewed/updated at least annually) one or more documented tasks per week / month Patients who fall within the identified cohort are followed for CC4C program evaluation / reporting. Both care management and claims data are analyzed for meaningful trends in quality, cost, utilization and CM activity. CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 1
Implementation Priority Populations: CCNC has been, and will continue to be, in a continuous state of revisiting and refining the information support, processes, and interventions as they develop new tools and resources (e.g. analytics) to help CCNC and CC4C care managers better manage their populations and prioritize care management activities. CC4C CM efforts should be aimed at impacting the following priority populations working in close collaboration with their CCNC Network: Children transitioning from the hospital back to the community As CC4C staff are trained in the transitional care model, they will be expected to work in close collaboration with CCNC care managers to serve these impactable families at a highly impactable moment (e.g. with NICU babies and infants/children who have been recently hospitalized). Children on the TREO Priority Population List (PPL) Because this list represents the Medicaid-eligible children felt to be most impactable in terms of improving quality of care and containing costs, it is considered a priority for follow-up. Real-time referrals - from Primary Care Physicians, CCNC Care Managers; NICUs; Emergency Department; other community providers; and community agencies/organizations. Other Data Reports (e.g., Current Hospital Visit Report; ED Visit Report; Inpatient Visit Report; Care Alerts; etc.). Suggestions for Prioritizing Patients within the PPL List: PPL patients who have had their most recent potentially preventable activity in the past 6 months should be a priority for CM services PPL patients flagged as newly enrolled in CA II should be a priority for CM services PPL patients deferred due to being well-linked should still be evaluated for appropriate use/volume/cost of services, effective coordination of care, avoidance of duplication, etc. PPL patients with CM status of deferred or inactive should be a priority for CM services CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 2
Action Steps: Implementation (Continued) During a brief/initial evaluation period, view CMIS documentation including the Comprehensive Health Assessment (CHA) and provider portal / claims data (including the patient snapshot), if available. Your goal is to obtain enough information to determine if the patient is impactable and initiate contact with the family. The next step is PATIENT ENGAGEMENT using motivational interviewing (MI) techniques. Once patient engagement is secured (and you have assigned the CC4C Care Manager and Program), initiate the Comprehensive Health Assessment (CHA). The CHA is a working document about the patient s past and current medical, behavioral, and social history and should be updated as new information is obtained. It serves as the patient s health record, allows the CM to identify and open conditions, and stays with the patient as he or she moves from one area of the state to another or across eligibility programs. Any staff who have access to CMIS should be able to review a CHA and feel secure that they are aware of pertinent medical information that will assist them in providing services to the patient. In addition, for specified target populations, document a Life Skills Progression (LSP) Assessment initially (within the first two contacts). [See Case Status Guidance on page 5]. Following initiation of the CHA (and LSP for specified target populations), NEXT STEPS in the Care Management process include: Document Tasks and Interventions [Important! Always leave an active record with a pending task to assure that you have a reminder about next step(s) for each patient on your caseload]. Determine Follow up / Monitoring frequency Assign Patient-Centric Goals Assign Case Status (level of service intensity) Documentation in Case Management Information System (CMIS): CMIS is a secure, web-based system for the management of its enrollees that is a user-built, patient-centric, electronic record of care management activities. CMIS contains standardized health assessments, care plans, screening tools, disease management, health coaching modules, and workflow management features. ALL care management activities, interventions, tasks, progress toward goals, etc., are documented in CMIS. CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 3
Implementation (Continued) Documentation in Case Management Information System (CMIS) Continued: CCNC and CC4C staff will use CMIS to assess the impact of care management. Therefore, it is imperative that: care managers utilize the standardized processes defined in this plan to document in CMIS their involvement with the individuals receiving care management services; and that the documentation be consistent across CCNC networks, local health department CC4C staff and other programs using CMIS for care management documentation. CMIS is for reporting both individual and population level information. CMIS enables the CM to assess, plan, implement, and evaluate patient care management through use of the following modules: Accessing claims data and other clinical and patient-centric data Case Assignment Patient Assessment and Care Planning Medication Management Secure Messaging System CMs are to perform regular periodic status and goal reviews (in CMIS) every 90 days, at a minimum, while the patient is being care managed at Heavy or Medium status. CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 4
Case Status Case Status defines the Intensity level of care management needs for THE PATIENT (CHILD) and must reflect direct service with the child (or his/her family). Activities not directly related to a patient-centered intervention, e.g., attempted tasks related to engaging the patient, SHOULD NOT be counted toward case status requirements. Intense Care Management - Heavy: Potential exists to impact quality, cost and/or utilization with family s engagement / willingness to participate. Document an initial Comprehensive Health Assessment, update with relevant information on an ongoing basis and review/update at least annually. Document a Life Skills Progression Assessment initially (within the first two contacts) for specified target populations. Specified target populations include all children referred for toxic stress and other children, as appropriate, based on the professional judgment of the care manager. This may include children, not identified as being exposed to toxic stress, but who have developmental, social or behavioral health issues of concern. For those with identified needs that the family is willing to work on, repeat the LSP every 6 months & upon closure. 1 Document one or more patient-centric goals (as a part of developing a patient-centered plan of care in CMIS), with at least one documented and completed task per week or 4 per month, at a minimum. 2 Review and update case status and goal(s) (in CMIS) at a minimum of every 90 days for patients being care managed at Heavy and Medium intensity levels. Intense Care Management - Medium: Potential exists to impact quality, cost and/or utilization with family s engagement / willingness to participate. Document an initial Comprehensive Health Assessment, update with relevant information on an ongoing basis and review/update at least annually. Document a Life Skills Progression Assessment initially (within the first two contacts) for specified target populations. Specified target populations include all children referred for toxic stress and other children, as appropriate, based on the professional judgment of the care manager. This may include children, not identified as being exposed to toxic stress, but who have developmental, social or behavioral health issues of concern. For those with identified needs that the family is willing to work on, repeat the LSP every 6 months & upon closure. 1 Document one or more patient-centric goals (as a part of developing a patient-centered plan of care in CMIS), with at least one documented and completed task per month, but less than one per week. 2 Review and update case status and goal(s) (in CMIS) at a minimum of every 90 days for patients being care managed at Heavy and Medium intensity levels. 1 According to Linda Wollesen, author of the Life Skills Progression: An Outcome and Intervention Planning Instrument for Use with Families at Risk, the greatest impact on families from working on LSP-related goals is realized within the first 6 months. Based on that knowledge, it is important that we follow these families for a minimum of 6 months or longer [until identified needs are met (LSP domains hit target scores) or a specific deferral reason results in closure] in order to have LSP Longitudinal Outcome Measures that demonstrate the value of this component of our CC4C services. To have the maximum impact, family s working on LSP goals ideally should be contacted on at least a monthly basis (Heavy or Medium Intensity Level) for the first 6 months. These interim contacts can be done by phone or as face-to-face contacts in the community, practice or home setting. After the first 6 months, care managers can assess the family s progress and engagement, and select a case status based on that assessment. With the family s engagement, their progress along the continuum will continue. 2 Tasks can include activities done directly with the child/family as well as activities done on behalf of the child/family (keeping in mind the ultimate goal of family self-sufficiency and the importance of helping the family learn how to navigate the health and social services systems on their own behalf). CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 5
Case Status (Continued) Care Management - Light (Patient Maintenance) Patient has been referred to an outside agency and CM monitors to assure that linkage occurred, Maintenance of stable conditions/problems, and/or Population Management Services, e.g., resolution of health care access issue or mailings directed at program initiatives/prevention, etc. Minimum of one or more documented tasks per year (but not more than two per quarter). For someone in Light Case Status, use the Comprehensive Health Assessment and/or Task Notes, as appropriate, for documentation. Goal(s) may be documented as a part of a patientcentered care plan, as appropriate, but is not required. If the case status changes to Heavy or Medium, follow guidelines for the new case status. Specified target populations for receipt of the LSP should be followed based on the guidelines noted under Heavy or Medium Case Status and Footnote #1 (see previous page). Note: When bulk tasks are used to implement population management, CMIS records a task for each patient. Care Management Pending Period when newly identified patients are being assessed to determine level of care management required Pending Status should not be used for more than 30 days from date referral received.* If no decision regarding CM needs have been made within this timeframe, the patient s status should be changed to deferred. * Note: Patients with extended hospital stays (e.g. NICU babies, severe trauma, etc.) may stay in pending status longer than 30 days or status may be updated. Important! Care Managers are required to schedule a pending task for all patients who have a Case Status of Heavy, Medium, Light or Pending. CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 6
Case Status (Continued) Care Management - Deferred: Following an initial patient review/assessment and/or period of providing care management, it may be appropriate to set case status as deferred, if one of the following reasons applies: Well linked Term Identified Needs/Goals Have Been Met Unable to Contact (at least 3 documented attempts) Unable to Set/Work Toward Goals in Care Plan Refused Services Does Not Qualify for CM at this time PCP Recommends Deferral Deceased Does Not Meet CC4C Screening Criteria Definition Patient assessment reveals no care management needs at this time because patient is well-linked to medical home and/or other services. Identified needs/goals for patient have been resolved as a result of CC4C activity. CM is no longer providing CM services. (One should select this reason only if CM services have been provided previously). CM has attempted contact at different times/different days/different ways and been unsuccessful. CM has made multiple attempts to help family set and work toward meeting goals in patient-centered plan of care without success. User should select this after she/he has attempted to work with the family on behalf of the child and has notified the PCP of the circumstances resulting in deferral for this reason. (This is not based upon PCP request to defer). Patient/family verbalizes he/she does not want CM services at this time or refuses referral for linkage. Patient does not qualify for CM services at this time due to living facility (i.e., institution) or other circumstances that prohibit patient/family from setting goals. This is the appropriate deferral reason for a child that has reached 5 years of age and no longer qualifies for CC4C. Patient is deferred at PCP s request/recommendation. Deceased No identified care management needs at this time based upon CC4C referral criteria. Target populations include children with special health care needs; children in foster care; infant in NICU; child exposed to toxic stress; children referred by CCNC Network staff or medical home; and children identified through Informatics Center Reports with priority given to children flagged on a Priority Population List and children needing transitional care services. CC4C Care Management Standardized Plan (3/1/2012 Revision) Page 7