progress note training (tcm)

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Family Preservation Services - Florida

Medicaid Mental Health Targeted Case Management Technical Assistance Review

Presented by Kerri Pawlak and Cheryl Buss (LCSW)

October 11, 20111

110/11/2011Family Preservation ServicesArea Eight Medicaid Technical AssistanceAgency Certification RequirementsEvery enrolled Medicaid Mental Health Targeted Case Management (MH-TCM) location must be Certified by the local Area Medicaid office before Medicaid reimbursable services can be delivered from the service location. Certification is awarded after the provider location has been successful (100% compliance) in passing the Certification Review. July 2006 MH-TCM Coverage and Limitations Handbook, pages1-5 and 1-62

Results of the Certification of the Naples LocationCertification Tool is broken down into two domains:Administrative Targeted Case Management (TCM) Review (54.54%) ComplianceProgrammatic Targeted Case Management (TCM) Review (40%) Compliance

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Findings from a Review of the MH-TCM Program in NaplesProgrammatic Findings from the Review:It was unclear whether the TCM met educational requirements because she had a foreign diploma.Four of 10 clients did not appear to meet minimum standards to receive MH-TCM services.Caseloads were always maintained within Medicaid policy parameters. Services were always rendered by agency certified case managers, but were not always rendered in accordance with Medicaid policy. Case Management Assessments were inadequate and did not address all components required.

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Findings from a Review of the MH-TCM Program at NaplesProgrammatic Findings from the review (contd)Two of 10 Assessments did not document a home visit with the client.The Assessment was dated by the recipient, case manager and treatment team members on different dates, with the supervisor being the first to sign, as opposed to the case manager. Service Plans did not contain measurable goals and objectives or include the amount, frequency and duration of services. 5

Findings from a Review of the MH-TCM Program at NaplesProgrammatic Findings from the review (contd)One Service Plan was inadequately documented. Progress notes did not meet documentation requirements, adequately justify the length of time spent, nor did they consistently link services to the Service Plan or Review. MH-TCM services rendered in conjunction with other Medicaid reimbursable service, when rendered to provide/communicate critical information that assists the recipient often exceeded the two units per event limit.Documentation was not entered in the record timely.

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Area Eight Medicaid Technical Assistance10/11/2011Family Preservation Services6Medical NecessityAll Medicaid services must be medically necessary. Clear and comprehensive documentation of all assessments, home visits, recipient interactions, and contacts with collateral sources should adequately show the strengths/needs of the recipient /natural support system.Documentation is the key to justifying/supporting the medical necessity of the service being provided.If the information is not documented, an auditor cannot allow reimbursement of the service.

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What is MH-TCMSupportive services which assist individuals to obtain needed medical, financial, insurance benefits, employment, social, educational and/or other services to appropriately address their needsIt is not the provision of direct therapeutic medical or clinical services July 2006 MH-TCM Coverage and Limitations Handbook, pages 2-7 and 2-8

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Accomplishing the Goal of MH-TCMIdentify the persons problem(s) by assessing the person to determine that persons needs.Create a Service Plan to outline the strategy for assisting the client in achieving his/her goals.Advocate for your client by linking the client to the services outlined in their service plan.Organize and monitor service delivery to evaluate the recipients progress.

July 2006 MH-TCM Coverage and Limitations Handbook, page 2-17

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Recipient CertificationChildrens and Adult Recipient MH-TCM CertificationsThe recipient certification form should document initial eligibility for MH-TCM services.

Appendix I-K:Recipients are certified by the Case Manager and the Case Management SupervisorCertifications must be completed within 30 days of initial date of service.It is possible that a referred client may not meet eligibility criteria, even if the referral source wants the individual to receive MH-TCM.

July 2006 MH-TCM Coverage and Limitations Handbook, pages 2-3 through 2-510

On-going EligibilityThe Service Plan Review is a process conducted to ensure that services, goals and objectives remain appropriate to the recipients needs and to (re)assess recipient progress and continued need for MH-TCM. The activities, discussion and review process must be clearly documented.Minimally, the Review is signed by the recipient, the MH-TCM and the MH-TCM supervisor.July 2006 MH-TCM Coverage and Limitations Handbook, page 2-16

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Covered Services*Conducting the MH-TCM Assessment and Service Plan in accordance with the handbook.Service Plan implementation with the client/family.Assessing service plan effectiveness.Linking, facilitating, coordinating and monitoring services delivered as defined in the Service Plan.Advocate for delivery of medically necessary services, as identified from the Service Plan.Documenting the delivery of MH-TCM.Providing access to resources during moments of crisis.Staffing(s) with the recipient treatment team or one-on-one with the psychiatrist, psychiatric ARNP, physician, therapist, teacher, attorney, GAL or other collateral. July 2006 MH-TCM Coverage and Limitations Handbook, page 2-1712

Covered ServicesTCM billed in conjunction with another Medicaid service when communicating critical client info.This cannot exceed two units per event.Coordination of aftercare upon discharge from a residential/inpatient facility when the facility is not paid a discharge planning per diem.Participating in the clients individualized Treatment Plan Development/Review process.Time billed must be clearly justified as time dedicated to the recipient.Providing MH-TCM services during the last 90 days of a childs BHOS stay.


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Service RestrictionsProvision of direct care servicesOffering clinical services, transportation, etc.Performing Administrative Functions:Copying, mailing, faxing, checking recipient eligibilityDischarge planning when covered by a residential facilitys per diem rate.Medicaid reimburses d/c planning 60-days prior to discharge from a state mental health facility.Ineligible Medicaid recipientsFACT recipientsJuly 2006 MH-TCM Coverage and Limitations Handbook, pages 2-8, 2-9 and 2-11

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Service RestrictionsHome & Community Based Waiver ClientsInstitutionalized Recipients Jails, Prisons, Detention Centers, ICF-DDs, etc.Institution for Mental DiseasesHospital/other institution with 17 or more beds, engaged in providing diagnosis, treatment and care to individuals with behavioral diseases (i.e.-some CSUs) Supervision is not a billable MH-TCM activity. Incomplete Certification Form, Assessment, Service Plan.July 2006 MH-TCM Coverage and Limitations Handbook, pages 2-9 and 2-1115

Service RestrictionsNo Recipient Contact (direct contact is required)Messages on machines, notes on the clients door and e-mail messages are not reimbursable.Non-Duplication of ServicesNo reimbursement for simply being present during a face-to-face therapeutic activity.Services provided which duplicate what is already being provided, regardless of the funding source (i.e.-services coordinated by family/CBC worker, etc.).TransportationMedicaid does not reimburse case managers for transporting recipients.

July 2006 MH-TCM Coverage and Limitations Handbook, page 2-11 and 2-12

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Service RestrictionsStatewide Inpatient Psychiatric Pgm (SIPP)TCM can be rendered the last 180 days of SIPP.Clinical information must be provided by the TCM to the SIPP at time of admission.MH-TCM must attend monthly treatment team meetings and remain in contact with the therapist, relevant collaterals, family & the child.Staff can attend by phone when clients are placed outside the districtThis must be justified in the clinical record


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Service RestrictionsSIPP Restrictions ContinuedThe MH-TCM follows up with the recipient for two months after discharge to collect SIPP outcome data.Services are limited to 8 hours/mo. during the SIPP stay; this is increased to 12 hours/mo. in the last month of care.


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Documentation ComponentsRequired documentation for each Case Management Record:Certification FormMH-TCM AssessmentService Plan and ReviewsService documentation with required elements

July 2006 MH-TCM Coverage and Limitations Handbook, pages 2-2, 2-4, 2-12, 2-15, 2-16, 2-20

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Documentation ComponentsRequirements for Case Management Notes:Recipients name; Date of service w/beginning & end times;Detail of the services provided;Setting where service was rendered (home, office, etc.);Updates when there is a significant change in:Residence, inpatient/state mental hospital placement, mental status, persons life/support system, custody or educational/ employment placementInclusion of MH-TCMs name, original (handwritten or electronic) signature, title and date. Photocopied signatures are not allowed.July 2006 MH-TCM Coverage and Limitations Handbook, page 2-20

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Documentation ComponentsDetailed Case Notes Must:Clearly link the case management activity with one or more identified, reimbursable Service Plan activities;Refer to Service Plan Objectives;Describe the recipients progress related to the Service Plan;Justify the time spent providing MH-TCM services.Document MH-TCM substitution, when rendered.July 2006 MH-TCM Coverage and Limitations Handbook, page 2-20

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Purpose of DocumentationThere is connection between the assessment, service planning, TCM activities and treatment services provided. Everything is coordinated through the MH-TCM Service Plan and MH-TCM documentation allows an auditor to understand the service planning and implementation process.

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Linkage AdvocacyServices/Tx.Client NeedsCollateral Input.Assessment & Service Planning

Continuous Review & Adjustment of Services CaseManagerAssessment and Service Planning

23MH-TCM AssessmentsAssessment must be completed within 30-days of client referral.A home visit must occur prior to completion of the initial assessment.


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MH-TCM Assessment Elements*Presenting problem(s) including history, self assessment; Psychosocial history;Psychiatric and medical history;Recipient current and potential strengths;Strengths/resources available through natural support system;Educational placement, adjustment and progress;Relationship with family and significant others;Identification and effectiveness of received services;Identification of services to assist client in reaching his goals;Assessment of service needs in the following areas:Mental Health; Alcohol/drug abuse; Family support and education; Education, Vocational/Job training; Housing, Food, Clothing or Transportation; Medical and Dental; Legal assistance; Development of environmental supports; Assistance with Financial Resources.July 2006 MH-TCM Coverage and Limitations Handbook, pg. 2-13

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MH-TCM Assessments*Assessment documentation must reflect that the following information sources were used:Recipients own perception of his/her situationThe referral source; Recipients family/friends;Other care providers serving the recipient;Information from previous treating providers, after a release of information is obtained.If collateral/other provider information is not obtained, documentation must justify this in the record.July 2006 MH-TCM Coverage and Limitations Handbook, pg. 2-13

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Assessment Documentation

An identifiable and dated document in the record; Contains information from initial screening and other sources: copies of evaluations, discharge summaries and other gathered data;Documentation of the home visit done prior to the completion of the assessment; Justification for lack of a home visit is required with sign-off by the case management supervisor.A face-to-face evaluation with the client still must occur.The assessment must be reviewed, signed and dated by the MH-TCM and their supervisor prior to completion of the Service Plan.

July 2006 MH-TCM Coverage and Limitations Handbook, pg. 2-14

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MH-TCM Assessment UpdatesMH-TCM Assessments must be updated annually.It is not recommended that Assessment Updates cite No Change or Status Unchanged as this does not document assessment of the recipients status, progress, needs or present functional level.


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Service Plan ElementsSingle identifiable document (not also the tx plan).It is individualized to the recipient.It requires measurable goals/objectives consistent with the MH-TCM assessment.It must be developed and finalized by the supervisor within 30 days after intake.Developed in partnership with and signed by the recipient, (guardian, if applicable), TCM and supervisor.July 2006 MH-TCM Coverage and Limitations Handbook, page 2-15

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Service Plan ElementsThe Service Plan describes needed services and indicates how needs will be met.The plan identifies timeframes for goal achievement.It includes short and long-term goals.It identifies who will be responsible for providing specific assistance/services, and should be consistent with the treatment plan.


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Service PlanningThe Service Plan should:Be a working, functional tool used to plan services that address client needs. Reflect assessment findings and case monitoring activities (i.e.-home visits, communication with treatment providers/ collateral sources, and ongoing face-to-face interactions with the client).Through these activities the client and case manager can evaluate needs/goals, and make adjustments to the Service Plan. 31

Service Plan ReviewsService Plan must be reviewed at least every six months and documented in the record;Revisions are done as significant events occur. Reviews must include a re-evaluation of the recipients eligibility for ongoing TCM.Documentation must indicate client still meets criteria to receive TCM services.The activities, discussion and review process must be clearly documented.The recipient, TCM, supervisor (and legal guardian, if applicable) must sign and date the Review.


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Examples of non-reimbursable MH-TCM ServicesThe following are from past and present MH-TCM FPS documentation:Childrens Case Management notes documented provision of services which were directed to the childs parent(s) instead of being directed toward the child-Services should be rendered to the recipient, and should meet their individualized needs as identified from the MH-TCM Assessment and Service Plan/Reviews.Services were managed by the childs foster parents, and there was not documented need for MH-TCM.-Duplication of services is not allowable.33

Examples of non-reimbursable MH-TCM ServicesCase manager did not document regression of child and evidence of TCM eligibility was not clearly indicated; however, other documentation showed that the child was referred for a QE and required SIPP admission -documentation did not justify on-going TCM eligibility although services were needed.Documentation contained discussion between the TCM and supervisor regarding what the TCM would be doing in the future. No active service provision was documented-MH-TCM did not provide a billable service and documented receipt of supervision.

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Examples of non-reimbursable MH-TCM ServicesSome documentation in a clinical file referred to how the boys were doing (client was in foster care with his brother).-Documentation should be reflective of services and needs specific to the client. Client was identified to have developmental disabilities (DD), though it was not determined whether the individual was in the DD waiver-Recipients cannot receive TCM and Waiver services at the same time.

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QUESTIONS????36Helpful Links/ResourcesMedicaid Summary of Services Link:http://ahca.myflorida.com/Medicaid/flmedicaid.shtmlMedicaid Fiscal Agent Website:http://mymedicaid-florida.comGet handbooks and enrollment forms hereMagellan Medicaid Administration (MMA):https://florida.fhsc.com/Get monitoring guidelines and MMA Power Point presentations here

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Helpful Links/ResourcesAgency for Healthcare Administrationwww.fdhc.state.fl.usSign up for Medicaid Health Care AlertsSee Agency announcements, publications, noticesMake a public record requestReport fraudDepartment of Children and Familieswww.dcf.state.fl.us

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Contact InformationKerri PawlakArea Eight Medicaid Behavioral Health Specialist239-335-1272E-mail: [email protected] L. Buss, LCSWArea Eight Medicaid Utilization Management Specialist239-335-1259E-mail: [email protected]

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progress note training (tcm)

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