1. TARGETED CASE MANAGEMENT (TCM) Requirements and Process Presenters: Maggie Fleming and Pat Ericsson

2. TODAY'S PRESENTATION Determining if TCM is a good fit for your program:  What to look for when analyzing a program for TCM;  A review of TCM target populations;  Case manager qualifications; and  Program Example

3. Provider Participation Agreement (PPA) Established procedure for Freedom of Choice Time Survey – Perpetual? Training? TCM Cost Report MOU with Managed Care Encounter logs Quality assurance plan Documentation/Client files/Confidentiality Access TCM System/ TCM LGA Profile Request Method to determine Medi-Cal Eligibility – MEDS 3 rd party liability Requirements to Participate

4. IS TCM FOR YOU?  Does the program have federal funding?  Does the program serve Medi-Cal clients and Non-Medi-Cal Clients?  Does the program provide comprehensive case management or one-time services?  Capacity Issues

5. … CONTINUED  Does the program serve any of the 5 Target Populations?  Does the program have adequate CPE? Does staff meet the TCM Case Manager Qualifications and Agency?

6. WHAT IS TCM? TCM consists of case management services that assist Medi-Cal eligible individuals within specified Target Populations to gain access to needed medical, social, educational, and other services

7. WHAT TCM IS “NOT” Non-TCM = Provider Direct Care & Treatment Teaching Educating Instructing Counseling

8. 4 TCM SERVICES TCM includes providing: Activity #1: Assessment/Periodic Assessment Activity #2: Development of a written Care Plan and Periodic Review Activity #3: Referral and Linkage Activity #4: Monitoring and Follow-up

9. TCM TARGET POPULATIONS 1.Children Under the Age of 21 (SPA 14) 2.Medically Fragile (SPA 15) 3.Individuals at Risk of Institutionalization (SPA 16) 4.Individuals in Jeopardy of Negative Outcomes (SPA 17) 5.Individuals with a Communicable Disease (SPA 18)

10. RISK FACTORS FOR SPAs 14,15,16,18 Failure to take advantage of necessary health care Noncompliance with medical regime Inability to coordinate multiple medical/social/other services Due to an unstable medical condition

11. … CONTINUED Inability to understand medical directions Due to comprehensive barriers Lack of community support for follow up care Substance abuse A victim of abuse, neglect or violence

12. CHILDREN AT RISK Risk factors can apply directly to a client or indirectly through client’s caregiver: —Mom places baby (client) at risk if she can’t get baby to health care appointment Children should be under 21 years old on the date of service

13. MEDICAL FRAGILE Client must have 2 or more diagnoses: —Disease, injury or condition —Physical, emotional, mental May be self declaration Does not need a health practitioner diagnosis

14. EXAMPLES OF INABILITY TO COORDINATE CARE Confusion about hospital appointment systems Doesn’t know who to contact for care Easily confused or low literacy levels New immigrant

15. RISK FACTORS FOR SPA 17 Substance Abuse in the immediate environment History of or in danger of family violence History of or in danger of physical, sexual or emotional abuse Experiencing substandard housing Illiteracy

16. ILLITERACY EXAMPLES No knowledge/skill to read the label on medications Unable to read & comprehend educational pamphlets Unable to comprehend & use bus schedule Unable to calculate how much change they should receive after a purchase

17. SUBSTANDARD HOUSING EXAMPLES Loss of utilities Overcrowding Cost burden Inadequate maintenance or sanitation Unsafe neighborhood Threat of eviction Temporary housing

18. Agency Qualifications To provide TCM services, the provider agency must: Meet the TCM Provider qualifications Have a signed Provider Participation Agreement (PPA) with DHCS Be an authorized provider of TCM services as listed in the CA State Plan Amendment (SPA) 42 CFR sections 441.18 (a)(8)(v) & 441.18 (b)

19. CASE MANAGER QUALIFICATIONS A Registered Nurse, or a Public Health Nurse with a license in active status to practice as a registered nurse in California; individual shall have met the educational and clinical experience requirements as defined by the CA Board of Registered Nursing, or

20. … CONTINUED An individual with a Bachelor’s degree from an accredited college or university, who has completed an agency-approved case management training course, or

21. … CONTINUED An individual with an Associate of Arts degree from an accredited college, who has completed an agency-approved case management training course and has two years of experience performing case management duties in the health or human services field, or

22. … CONTINUED An individual who has completed an agency-approved case management training course and has four years of experience performing case management duties in a health or human services field.

23. INTEGRATING TCM IN YOUR PROGRAM Care Plan/Periodic Review must be completed every 6 months Follow up must be done within 30 days of referral OR date of service A comprehensive assessment of client must be documented

24. Has Medi-cal or is Medi-Cal eligible Is in need of assistance in accessing services Meets the target population designated for TCM CLIENT ELIGIBILITY CRITERIA

25. Is not receiving Case Management Services from another TCM Provider Is not receiving Case Management Services from a Managed Care Provider Is not enrolled in a 1915 c Home Community Based Service Waiver Program CLIENT ELIGIBILITY CRITERIA

26. … CONTINUED Freedom of Choice —Services are voluntary, can choose case manager, may terminate services. Fee Determination & Waiver —Providers must have an established fee mechanism specific to TCM services, which may include a sliding fee schedule based on income.

27. … CONTINUED Duplication of Services —Case manager must document that services being provided are not duplicating services provided by other programs and/or agencies. —3 levels of screening: Case Management, Managed Care, & Waiver 1915C better known as “Home and Community Based Services”

28. PROGRAM EXAMPLE Catholic Charities, Sonoma County:  Bringing LGA Coordinator to help with buy-in from management  Integrating TCM requirement into current program forms

29. IS TCM A FIT?  Program not Federally Funded  Client population is Individuals at Risk of Institutionalization  Program provides health services and case management to homeless adults who have been discharged from the hospital and are in need of additional recuperation.

30. … CONTINUED  Determine if clients served meet Target Populations  Determine if CPE is available  Determine which staff would participate in TCM  Determine if existing forms need to be updated to meet TCM requirements.

31. ENROLLMENT PROCESS  Update forms to meet TCM requirements  Set up time study  Review accounting requirements with fiscal staff  Include CBO in Provider Participation Agreement  Pilot and do internal audit

32. RESOURCES  Monthly Conference Calls with TCM Workgroup  The FAQ’s – website  LGA Assistance – ask for help from your LGA coordinator

33. Questions?