Targeted Case Management Encounters Program Implementation TCM Documentation Training November 1, 2012 Targeted Case Management Encounters Program Implementation 2016 LGA Consortium Annual Conference “Best practices” are noted and are not required by DHCS Resources are listed at the end of this presentation to ensure State mandates are met Beverly S. Randolph – San Diego County Sue Guest – Contra Costa County

TCM Documentation Training November 1, 2012 Are You Ready? Fee Mechanism Encounter Log Documentation Annual Participation Prerequisite (APP) Provider Participation Agreement (PPA) Policies National Provider Identification (NPI) Number For Agency and For Case Managers Engagement Policy/Referral Response Managed Care MOU Refer to powerpoint from Session O List elements need to be in place before providing TCM services to clients. 2016 LGA Consortium Conference - Targeted Case Management and Encounters Program Implementation

TCM Documentation Training November 1, 2012 First Visit Determine Target Population Assess for Duplication of Services Administer the Fee Mechanism Freedom of Choice/Voluntary Services Confidentiality/ HIPAA/Release of Information Introductions of Program Contact Information Comprehensive Assessment who else is involved in providing services to the client? Managed Care Plans? 1915 C HCBS waiver? Coordination? Others? What type of insurance? Medi-Cal? No coverage? Fee Mechanism? Medi-Cal number? Mandated reporters Targeted Case Management and Encounters Program Implementation

TCM Flow: Assess the Client TCM Eligibility Comprehensive Assessment Care Plan Referrals Client Progress Reassess and Revise Targeted Case Management and Encounters Program Implementation

The Four TCM Service Components TCM Documentation Training November 1, 2012 The Four TCM Service Components Assessment/Periodic Assessment Care Plan Development/Periodic Reassessment Referral Activities Monitoring and Follow-up Talk about numbering components. 1 – Assessment and Periodic Assessment, 2 – care plan, 3- referral activities, 4- monitoring and follow-up Targeted Case Management and Encounters Program Implementation

What’s Required for Assessments TCM Documentation Training November 1, 2012 What’s Required for Assessments The client’s needs/problems are documented: In conjunction with the client Must be comprehensive May take more than one visit Done face to face Crisis and emergencies Targeted Case Management and Encounters Program Implementation

Comprehensive Assessment TCM Documentation Training November 1, 2012 Comprehensive Assessment Medical/Mental Community Living/Life Skills Vocational/Educational Physical Social/Emotional Family Social Support Housing/Physical Legal Anything that could negatively effect the well-being of the client Not an exhaustive list Targeted Case Management and Encounters Program Implementation

Comprehensive Assessment TCM Documentation Training November 1, 2012 Comprehensive Assessment If the Assessment occurs over multiple visits, then document: Specific aspects addressed in each encounter Why the Assessment could not be completed in one encounter Why multiple face-to-face encounters are required to complete the Assessment Examples: Client been uncooperative Client is very talkative Client had to leave Client has short attention span Client would answer 10 questions. Case manager has been at home for 3 hours…..time to leave Targeted Case Management and Encounters Program Implementation

Comprehensive Assessment TCM Documentation Training November 1, 2012 Comprehensive Assessment If the client has no needs in an area of the Assessment a separate note is not necessary. Sufficient documentation is a statement or checkbox stating: “No needs identified ” Talking point: Comprehensive assessment is done, and CM find no needs or problems. There is no care plan. Assessment is a billable visit, but no further encounters should be billed as the client no need or problems. In a program if you have a high percentage of 1x visits, open and close visit, it will be questioned whether your program is actually providing Targeted Case Management. Targeted Case Management and Encounters Program Implementation

TCM Flow: Develop a Care Plan TCM Eligibility Comprehensive Assessment Care Plan Referrals Monitor Reassess and Revise Targeted Case Management and Encounters Program Implementation

TCM Documentation Training November 1, 2012 Care Plan Must be developed with the client Goals and referrals must be linked to needs identified in the Assessment Must be signed by: Case Manager Supervisor Examples of developed with client. Client smokes, should stop and doesn’t see as problem Time frame for signature. Ask audience what is the time frame for the supervisor’s signature. Targeted Case Management and Encounters Program Implementation

Care Plan Must include frequency and duration May be completed during the Assessment encounter Bill for either Assessment or Care Plan Development Targeted Case Management and Encounters Program Implementation

Frequency and Duration TCM Documentation Training Frequency and Duration November 1, 2012 Frequency How often the Case Manager needs to visit the client Duration How long the Case Manager needs to visit the client “As needed” is not sufficient Frequency and duration should be base on the CM’s assessment and plan. Example : Cm visit 1 time a week for 3 months. Program should develop their own internal policies for the duration between face to face encounters. Duration for period time – 3 months, 6 months. Targeted Case Management and Encounters Program Implementation

TCM Flow: Make Referrals TCM Eligibility Comprehensive Assessment Care Plan Make Referrals Monitor Reassess and Revise Targeted Case Management and Encounters Program Implementation

TCM Documentation Training November 1, 2012 Referral Activities Referrals must be linked to needs identified in the Care Plan No referrals are too minor, as long as they relate to the health and well-being of the client If a new need is assessed, and a new referral made – update the Care Plan Targeted Case Management and Encounters Program Implementation

TCM Documentation Training November 1, 2012 Referral Activities Types of Referrals Case Manager refers a client to a service and makes an appointment Case Manager encourages client to use a resource Examples Targeted Case Management and Encounters Program Implementation

Referral Activities Multiple Referrals If a client does not utilize a referral, Case Manager may offer more referrals Document: Why additional referrals are needed How the Case Manager is addressing barriers Targeted Case Management and Encounters Program Implementation

TCM Documentation Training November 1, 2012 Referral Activities Family Referrals: Referrals that meet the needs of multiple family members may only be billed to one TCM client Example: Housing. If give the referral to the mother, cannot use the same referral for the infant. Targeted Case Management and Encounters Program Implementation

TCM Flow: Monitor Progress TCM Eligibility Comprehensive Assessment Care Plan Referrals Monitor Reassess and Revise Targeted Case Management and Encounters Program Implementation

Monitoring and Follow-Up TCM Documentation Training November 1, 2012 Monitoring and Follow-Up All referrals with an appointment date must be followed up within 30 days Follow-up may be: Face-to-Face Phone Text Mail The initial referral encounter may be disallowed if follow-up is not performed within the 30 days Talking point: Be sure to point out that only face-to-face is billable Targeted Case Management and Encounters Program Implementation

Monitoring and Follow-Up TCM Documentation Training November 1, 2012 Monitoring and Follow-Up All referrals receive a follow-up! Talking point – All referrals receive a follow-up whether there is a scheduled date or not What happens if the CM cannot follow up with the client within 30 days? Must document why they couldn’t follow up – what barriers? Targeted Case Management and Encounters Program Implementation

Monitoring and Follow-Up Documentation TCM Documentation Training November 1, 2012 Monitoring and Follow-Up Documentation Did the client utilize the referral or attend the appointment? What was the outcome of the appointment? Did the referral meet the client’s needs? If not why? What are the next steps or further actions needed to meet the client’s needs? Targeted Case Management and Encounters Program Implementation

TCM Flow: Reassess and Revise TCM Eligibility Comprehensive Assessment Care Plan Referrals Monitor Reassess and Revise Targeted Case Management and Encounters Program Implementation

Periodic Reassessment TCM Documentation Training November 1, 2012 Periodic Reassessment When the client’s circumstance has changed such as: Eviction Birth of Baby Domestic Violence Hospitalization Happen at anytime Targeted Case Management and Encounters Program Implementation

Periodic Reassessment Update the existing Care Plan New Need New Referral Targeted Case Management and Encounters Program Implementation

Periodic Reassessment and Care Plan Review TCM Documentation Training November 1, 2012 Periodic Reassessment and Care Plan Review Shall be conducted at least every six months Modify the care plan to address new needs and/or conditions Must be signed by Case Manager and Supervisor If a reassessment has not been done in at least 6 month, then need to do to determine if an individual’s needs and/or conditions have changed. Can do together In the Reassessment CM would review the areas addressed in the comprehensive assessment. Targeted Case Management and Encounters Program Implementation

TCM Documentation Training November 1, 2012 Care Plan Review Entire Care Plan should be reviewed with the client to determine: What needs and goals have been met or not met Whether services should be continued, modified, or ended A new Care Plan is not necessary if new needs are not identified When to cease TCM services Targeted Case Management and Encounters Program Implementation

TCM: Case Management & Encounters Program Implementation TCM Documentation Training November 1, 2012 TCM: Case Management & Encounters Program Implementation Targeted Case Management and Encounters Program Implementation

TCM: Case Management & Encounters Program Implementation For More Information or Answers Monthly Conference call Meetings with the “TCM Guidelines Workgroup” The TCM FAQs Website Your LGA Coordinator Targeted Case Management and Encounters Program Implementation

TCM: Case Management & Encounters Program Implementation TCM Documentation Training November 1, 2012 TCM: Case Management & Encounters Program Implementation Targeted Case Management and Encounters Program Implementation