case management maintenance galynn thomas, rn, msn children’s medical services

Case Management Case Management MaintenanceMaintenance

Galynn Thomas, RN, MSNGalynn Thomas, RN, MSN

Children’s Medical ServicesChildren’s Medical Services

Complex Case ManagementComplex Case Management

• Low case loadsLow case loads

• High complexity casesHigh complexity cases

• Regular CCS case Regular CCS case

managementmanagement

CCSNL Ongoing CCSNL Ongoing ResponsibilitiesResponsibilities

• Communication & OversightCommunication & Oversight

• Monitoring & MaintenanceMonitoring & Maintenance

• F-CAP – Authorizations F-CAP – Authorizations

(SARS)(SARS)

• AssurancesAssurances

Communication & OversightCommunication & Oversight

• Communication Communication

• Collaboration Collaboration

• CoordinationCoordination

Communication Collaboration Communication Collaboration CoordinationCoordination

• MessageMessage

• CommuniquéCommuniqué

• AnnouncementAnnouncement

• StatementStatement

• ContactContact– LetterLetter

– EmailEmail

– Phone callPhone call

• Team work Team work

• PartnershipPartnership

• Group effort Group effort

• AssociationAssociation

• AllianceAlliance

• Relationship Relationship

• CooperationCooperation

• HarmonizationHarmonization

• OrganizationOrganization

• ManagementManagement

• SynchronizationSynchronization

• Bringing Bringing

TogetherTogether

• DexterityDexterity

CommunicationCommunication• MultidisciplinaryMultidisciplinary• SCCSCC• Care CoordinatorCare Coordinator• Participant/ Family/ Circle of SupportParticipant/ Family/ Circle of Support• Referring PhysicianReferring Physician• Medical HomeMedical Home• CMS BranchCMS Branch• Other County CCS staffOther County CCS staff

CommunicationCommunication

• LiaisonLiaison

• Technical assistance Technical assistance

• Oversee communication between CC and Oversee communication between CC and

referring CCS providers to improve PFC referring CCS providers to improve PFC

practicespractices

• Summarization communication in PFC DatabaseSummarization communication in PFC Database

Monitoring & MaintenanceMonitoring & Maintenance

• Monthly - Contact Participant/Family Monthly - Contact Participant/Family UnitUnit

• Review F-CAP – Review F-CAP – – Services requested appropriateServices requested appropriate– Meet the needs and goals ID – F-CAPMeet the needs and goals ID – F-CAP

• Services are provided Services are provided

(accordance with F-CAP)(accordance with F-CAP)– Frequency & DurationFrequency & Duration


• Participant/ Family Unit Access to CCSParticipant/ Family Unit Access to CCS

– ResourcesResources

– Case managementCase management

•TelephoneTelephone

•EmailEmail

•Direct contactDirect contact


• Participate PFC Case Management Participate PFC Case Management ConferenceConference– TelephoneTelephone– Direct contactDirect contact– Participant’s homeParticipant’s home– AgencyAgency– CCSCCS– Other facilitiesOther facilities


• Coordinate Medical ServicesCoordinate Medical Services– PFC ServicesPFC Services– State Plan Services – regular Medi-CalState Plan Services – regular Medi-Cal– EPSDT SSEPSDT SS– DischargeDischarge– TransitionTransition– HospitalizationsHospitalizations


• Provide InformationProvide Information– Range of ServicesRange of Services– Support GroupsSupport Groups– Community ServicesCommunity Services– ProviderProvider– Participant, Family & Circle of SupportParticipant, Family & Circle of Support– InquiresInquires


• Utilization ManagementUtilization Management– Evaluate need - servicesEvaluate need - services

– AuthorizationsAuthorizations

– Review claims paidReview claims paid• Frequency & duration in accordance with F-CAPFrequency & duration in accordance with F-CAP

• Track claims dataTrack claims data

– Review appropriateness of the provider Review appropriateness of the provider

selected.selected.


• Health & Welfare - Federal Assurance (FA)Health & Welfare - Federal Assurance (FA)– MonitoringMonitoring

•Health, Safety & Welfare of ParticipantHealth, Safety & Welfare of Participant

•On-going risk assessments (FA) by CCOn-going risk assessments (FA) by CC

•F-CAPF-CAP

– Evaluate risk of abuse, neglect & exploitationEvaluate risk of abuse, neglect & exploitation

– Review psychosocial risk factors Review psychosocial risk factors


• Health & Welfare Health & Welfare (cont.)(cont.)

– Document all reported or observed Document all reported or observed

critical events/incidents (FA)critical events/incidents (FA)

– Notify State CMS & send copiesNotify State CMS & send copies

– Follow-up – within 30 days Follow-up – within 30 days

– PFC Database PFC Database

Review of F-CAPReview of F-CAP

• At least every 60 daysAt least every 60 days

• Interim – as neededInterim – as needed

• ServicesServices

• GoalsGoals

• Risk FactorsRisk Factors

• Approve, sign, date, and returnApprove, sign, date, and return

Review of F-CAPReview of F-CAP

• HospitalizationsHospitalizations

• Emergency Department AdmissionsEmergency Department Admissions

• RespiteRespite

• Condition Changes – illness trajectoryCondition Changes – illness trajectory– LOC re-determinationLOC re-determination

• Care Coordinator hours Care Coordinator hours

• Therapy hours Therapy hours

• BereavementBereavement

Authorizations - SARsAuthorizations - SARs

• Service limitsService limits

• Appropriate providerAppropriate provider

• Special InstructionsSpecial Instructions

• PFC, State Plan, and EPSDT Supplemental PFC, State Plan, and EPSDT Supplemental

ServicesServices

• PFC DatabasePFC Database

Role of the Care CoordinatorRole of the Care Coordinator

• Coordinate all care Coordinate all care – PFC servicesPFC services– State Plan servicesState Plan services– Community resourcesCommunity resources

• CollaborationCollaboration– CCSNLCCSNL– Participant & familyParticipant & family– ProvidersProviders


• Educate and train participants & Educate and train participants & famiyfamiy

• Development of the F-CAPDevelopment of the F-CAP– ImplementationImplementation– RevisionsRevisions– Goals & servicesGoals & services

• Home visitsHome visits– Health, welfare and safetyHealth, welfare and safety


• Accompany to appointmentsAccompany to appointments

• Maintain recordsMaintain records– CorrespondenceCorrespondence

• Conduct monthly interdisciplinary Conduct monthly interdisciplinary team meetingsteam meetings

• Collaboration with CCS ProgramCollaboration with CCS Program

AssurancesAssurances

• Level of Care (LOC)Level of Care (LOC)

• F-CAP revisions – (Service plan F-CAP revisions – (Service plan

development & Delivery)development & Delivery)

• Service DeliveryService Delivery

• Freedom of ChoiceFreedom of Choice

• Health & Welfare ReportingHealth & Welfare Reporting

• RemediationRemediation

OtherOther

• Transition PlanTransition Plan

• Dis-enrollmentDis-enrollment

Dis-enrollmentDis-enrollment

• Change in health statusChange in health status

• MovedMoved

• DeclineDecline

• Hospitalization > 30 daysHospitalization > 30 days

• Loss full scope, no share of costLoss full scope, no share of cost

• Health & Safety issuesHealth & Safety issues

Dis-enrollment continuedDis-enrollment continued

• Compliance with appointmentsCompliance with appointments

• Enrolled in another 1915c HCBS Enrolled in another 1915c HCBS WaiverWaiver

• Reached 21Reached 21stst birthday birthday

• TransitionedTransitioned

• Passed awayPassed away

• QuestionsQuestions

case management maintenance galynn thomas, rn, msn children’s medical services

Documents