1. ASSURING YOUR TCM PROGRAM IS IN COMPLIANCE Presented by Patricia Calloway – Alameda County and Nancy Leidelmeijer – Santa Barbara County

2. Topic for discussion Case Manager qualifications Agency qualifications Program policies Audit file Best practices

3. Agency Qualifications Must have system of coordination between programs Demonstrate experience in providing case management Employ staff with CM qualifications Have or establish referral systems for linkages

4. Agency Qualifications – Cont’d 5 year minimum of providing CM to target group Administrative capacity to ensure quality of services Financial management capacity to comply with OMB A-87 Capacity to document and maintain case records to meet regulation standards Ability to evaluate quality and effectiveness

5. Case Manager Qualifications RN or PHN with active license Bachelor’s degree with agency approved CM training Documentation of initial and annual time survey training Duty statements NPI Documentation of case management training for Non – RN/PHNs

6. Program Policies Part of the Annual Participation Prerequisite: Performance Monitoring Plan/Non- duplication/Care Coordination Freedom of Choice Fee Mechanism Managed Care MOU

7. Program Policies - continued Policies Annual Participation Prerequisite subcontractors Provider Participation Agreement Signature Authority MEDS Access Sub program codes Third Party Liability

8. Program Policies - continued Policies TCM Payment System Time Surveys Confidentiality Duty Statements Payment by invoice Quality Assurance Chart audit and peer review

9. Audit File Organizational Charts Duty Statements/Job Description Case Management Qualifications Billable vs Non-billable Encounter Logs

10. Best Practices Duty Statements Client satisfaction Grievance procedure Required Documentation Red Flags Resources

11. Freedom of Choice Must have a Freedom of Choice policy Best Practice: Note on assessment form that Freedom of Choice was explained

12. Freedom of Choice Client must be told: Services are voluntary May go to a different TCM provider May request a different CM May terminate TCM services at any time

13. Fee Determination and Waiver It must be documented that the client was reviewed for a fee for TCM services Each LGA or TCM provider must have an income-based scale to determine if client must pay a fee There are no state or federal parameters

14. Fee Determination and Waiver If it is determined that the client must pay a fee, the fee may be waived by the Case Manager Client has a communicable disease CM determines client will not continue in the Program and could be detrimental to the client

15. Billable vs. Non-Billable A billable encounter is: Face-to-face visit with Medi-Cal client In TCM target population During which case manager renders one or more TCM service components.

16. Performance Monitoring Plan LGA must submit their Performance Monitoring Plan with their Annual Participation Prerequisite. Details how LGA will ensure case management service will not be duplicated Details your Quality Assurance Plan

17. Quality Assurance No formal requirements exist – each LGA should determine its own QA protocols LGAs develop a written policy for reviewing TCM cases

18. Quality Assurance Best Practices Include criteria, sample methodology, and frequency of reviews May involve coordinator’s review, supervisor review and/or peer review Include periodic checks to assure that client case documentation, encounter logs, and billings are consistent in details

19. Common Documentation Errors Not clearly identifying the TCM service that was provided Not identifying one of the four TCM service components Billing for a TCM encounter when a TCM service has not been documented

20. Common Documentation Errors Not addressing who, what, when, where and why Not clearly distinguishing individual care plans, assessments and progress notes within family charts Not clearly identifying how a client meets the Target Population criteria

21. Red Flags for Auditors Not using TCM words in case file documentation Making frequent client visits without documenting client outcomes or new needs Documenting multiple home visits where no new information was received or new referrals made

22. Red Flags for Auditors Needs identified on the Assessment are not the same needs identified in the Care Plan Using local agency acronyms without a key to full names or meanings Illegible writing Documenting for a family versus an individual

23. Resources State Website LGA Website TCM FAQs MAA/TCM Regional Meetings TCM Guidelines Workgroup Annual Conference

24. Resources-FAQs View the complete FAQ document: https://sites.google.com/site/calgaco nsortiumworkgroups/home/tcm- workgroup/tcm-faqs

25. TCM FAQs

27. Questions