1. 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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

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

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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