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Presenter: Sandi Greenawalt Sandi Greenawalt RN MCHA-Wellness Promotion CCM, CCP, CPHQ Six Sigma Green Belt Manager Accreditation Services Case Management Accreditation v5.0 Date: Sept 16, 2015 Webinar Questions for the Faculty For questions, please send them via the webinar interface. Please reference either the standard number or the slide number. Each question will be answered by URAC’s faculty at the designated sections of today’s program. © 2015 URAC 2 Continuing Education Units/Credits Continuing Education Units/Credits • Approved for this education program Attendance • Registered participants must attend the entire program Evaluation • Registered participants earn at least 70 percent on the post-test • Registered participants can access evaluation up to 30 days after this education program © 2015 URAC Certificate • You will have the option to print your certificate(s) after providing some demographic 3 Presenter Sandi Greenawalt RN MCHA-Wellness Promotion CCM, CCP, CPHQ Six Sigma Green Belt Manager Accreditation Services 9/10/2015 © 2015 URAC 4 About URAC Mission To promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measures. • Non-profit, independent entity • Broad-based governance Structure Strategic Focus Providers Employers Labor Payers Regulators Consumers Expert Advisory Panels (Volunteer) • Consumer Protection and Empowerment • Improving and Innovating Health Care Management © 2015 URAC 5 “Fast Facts” About URAC Non-profit, independent organization founded in 1990; originally chartered to accredit utilization review services URAC offers over 30 distinct accreditation programs across the entire continuum of care URAC currently accredits over 600 organizations operating in all 50 states and internationally © 2015 URAC URAC’s accreditation programs are nationally utilized by state and federal regulators to ensure the highest level of quality is delivered to consumers 6 URAC Offers a Full Range of Accreditation and Certification Programs Health Plan Operations Healthcare Management Health IT & Information • Core • Health Plan* • Health Plan w/Marketplace Measures* • Health Network • Credentials Verification Organization • Claims Processing • Health Provider Credentialing • Dental Network • Health Utilization Management • Case Management* • Health Call Center • Workers Compensation Health Utilization Management • IRO • Disease Management* • Wellness* • Health Website • HIPAA Privacy • HIPAA Security • Consumer Education & Support • Health Content Provider • Clinical Integration • Accountable Care • PCMH Practice Certification Pharmacy Quality Management® • Pharmacy Core • Specialty Pharmacy* • PBM* • Mail Service Pharmacy* • Workers Compensation PBM* • Drug Therapy Management* • Community Pharmacy Notes: *Product with measures © 2015 URAC 7 Scoring Methodology Six distinct scoring categories: 1 = Emerging practice 2 = Basic infrastructure 3 = Promotes quality 4 = Key stakeholder right/empowers consumers M = Mandatory element with a direct or significant impact on consumer safety and welfare L = Leading Indicator - not weighted, optional element All mandatory elements must be met at 100 percent in order to achieve a full accreditation. © 2015 URAC 8 AccreditNet Application Instruction Booklet © 2015 URAC 9 Case Management v5.0 Underlying Principles CM Program Components Patient Education and Engagement • Identification Criteria • Evidence-Based Guidelines • Collaborative Communications • Define CM Role for Transitions of Care • Shared Decision Making • Performance Monitoring • Use of Information Support Systems to Improve Efficiency • Establish Outcome Measures • Patient-Centered • Incorporates Motivational Principles • Supports Patient SelfManagement • Engages Patient, Family, Caregiver • Patient Accountability • Health Education Tools • Cultural & Linguistic Learning Needs • Case Management Disclosure • Promotes Optimal Levels of Wellness © 2015 URAC Staff Training and Qualifications • Commitment to Excellence • Promotes Case Manager Expertise and Proficiency • Requires Use of Qualified Case Managers • Reinforces Competencies • Expands Role for Case Management Support Staff 10 Case Management v5.0 Underlying Principles (continued) Case Management Assessment and Plan • Identifies Critical Assessment Categories • Patient Input • Medication Safety Assessment (Adherence & Reconciliation) • Patient-Centered Case Management Plan • Culturally Relevant Care Coordination • Aligns with Health Care Reform goals for better coordinated care. • Fosters Improved Coordinated Care • Supports Integrated Care Delivery • Social Services and Support • Patient-Identified Issues • Increase Quality and CostEffectiveness © 2015 URAC Transitions of Care “Optional Designation” • Planning for Transitions of Care Across Settings. • Individualized and Comprehensive Care Planning • Care Transition Information Transfer Requirements • Ensure Timely Follow-Up Interventions for Post Acute Care • Coordinated Approach to Reduce Readmissions 11 Measurement Reporting Reporting on Mandatory Measures • Requirement of accreditation and must be reported to URAC on an annual basis Reporting on Exploratory (Leading) Measures • Cutting-edge measures or measures under development © 2015 URAC 12 Case Management Program Measures Five Mandatory Measures – reporting is required for accreditation: – – – – – Medical Readmissions Percentage of Participants Medically Release to Return to Work Complaint Response Timeliness Overall Customer Satisfaction Percentage of Individuals Refusing Case Management Services Two Exploratory Measures – reporting is optional: – Three-Item Care Transition Measure – Patient Activation Measure Measure specifications are located in your AccreditNet Resource Library © 2015 URAC 13 Learning Objectives Attendees should be able to: Understand the accreditation standards Understand what is needed to meet the intent of the standards © 2015 URAC Determine the documentation that is needed to submit with the application 14 Overview Case Management v5.0 I. Case Management Program Components II. Consumer Education and Engagement III. Staff Training and Qualifications IV. Case Management Assessment and Plan V. Care Coordination VI. Transitions of Care – Optional for Designation VIII. URAC Education and Consumer Education © 2015 URAC 15 Crosswalk Table Case Management v5.0 and v4.1 © 2015 URAC 16 Case Management Program Components CM 1 – Program Description The organization has a program description and/or written policies and documented procedures for case management that includes: Clearly-defined program: – Objectives/goals; [2] – Interventions relevant to the full scope of services; [2] and – Case management program performance measures [2] Guidelines for establishing criteria to: – Identify consumers eligible/ineligible for case management services; [2] – Discharge and/or terminate case management services; [2] and – Determine and adjust individual case manager caseloads; [4] © 2015 URAC 17 Case Management Program Components CM 1 – Program Description (continued) Methodology used to measure savings attributed to case management such as return on investment (ROI); [L] Where available, incorporating evidence-based and/or clinical practice guidelines or case management guidelines for: – Consumer-centered case management plans; [4] – Clinical decision support tools; [4] and – Health information; [4] Guidelines for obtaining stakeholder input for consumer-centered case management plan development involving: – Consumer; [M] – Family/caregiver(s) chosen by the consumer; [M] and – Provider/health professionals/interdisciplinary team; [M] and © 2015 URAC 18 Case Management Program Components CM 1 – Program Description (continued) Guidelines that clearly define the role of the case manager regarding transitions of care for determining: – A consumer’s transitional care needs; [3] – Consumer-specific interventions related to transition of care needs; [3] and – How transitions of care needs are communicated to stakeholders (including consumers and family/caregiver(s)). [3] © 2015 URAC 19 Case Management Program Components CM 2 – Collaborative Communications The organization maintains written policies and/or documented procedures that support the case management process by identifying appropriate information-sharing to ensure effective communication between entities that include: Guidelines to promote collaborative communications between all stakeholders (including consumers and family/caregiver(s)) in the case management process; [M] and A process for clinical staff to consult with or seek advice from licensed health professionals with expertise appropriate to the condition and types of services being managed. [M] © 2015 URAC 20 Case Management Program Components CM 3 – Consumer Involvement in Shared Decision-Making The organization implements written policies and/or documented procedures that support a collaborative, shared decision making process. To meet that goal, the case management organization: Collaboratively identifies the types of information that will be made available on an as needed basis to consumers, families, and/or caregivers in support of: – Consumer self-management; [4] – Shared decision making; [4] and – Knowledgeable use of medications. [4] © 2015 URAC 21 Case Management Program Components CM 3 – Consumer Involvement in Shared Decision-Making (continued) Documents the health information, including health education tools, made available that support shared decision making; and [4] Obtains consent (verbal or written) for case management services from the: [4] – Consumer; or – Family and/or caregiver(s) chosen by the consumer. © 2015 URAC 22 Case Management Program Components CM 4 – Internal Performance Monitoring The organization monitors and evaluates case management program performance according to its written policies and/or documented procedures. To meet that goal, the organization will implement: Case management program performance measures supported by evidence-based and/or clinical practice guidelines, or case management guidelines where available (see CM 1); [3] A process to conduct ongoing systematic data analysis to evaluate if performance goals are met; [3] Requirements for at least annual reporting of case management program performance to the quality management committee; [3] © 2015 URAC 23 Case Management Program Components CM 4 – Internal Performance Monitoring (continued) A process to use case review findings to determine if case management program performance measures are being met; [3] and Guidelines for determining when situations trigger a review and possible criteria modifications for: – Consumers eligible and ineligible for case management services; [2] – Discharge or termination of case management services; [2] and – Adjusting case manager caseload. [4] © 2015 URAC 24 Case Management Program Components CM 5 – Information Support Systems In support of achieving its case management performance goals, the organization will implement an ongoing evaluation process for the use of electronic information systems. [3] © 2015 URAC 25 Consumer Education and Engagement CM 6 – Consumer Motivation and Engagement The case management organization implements documented practices that promote a collaborative process with the consumer and incorporates motivational principles that support consumers’ ability to: Make decisions regarding their individual consumer-centered case management plan; [4] and Identify and take action towards accomplishing self-management goals. [4] © 2015 URAC 26 Consumer Education and Engagement CM 7 – Consumer Education The organization educates consumers to develop and maintain selfmanagement skills. To meet that goal, program interventions address: Providing health education/information that supports the consumer, family, and/or caregiver’s ability to achieve the consumer-centric case management goals; [M] The use of culturally and linguistically appropriate services to reflect individual learning needs, if applicable; [2] The use of individual and personalized health education tools to reinforce self-management skills; [3] and Informing consumers, families, and/or caregivers of their role relative to transitions of care and interactions with healthcare providers. [3] © 2015 URAC 27 Consumer Education and Engagement CM 8 – Case Management Disclosure The organization implements written policies and/or documented procedures to educate consumers, families, and/or caregivers to promote informed decision making. This requires case management disclosure of the following information at the relationship onset: To promote transparency: – The nature of the case management relationship, particularly when a thirdparty payer is involved; [4] – Guidelines or rules used to determine when information obtained in the case management relationship will be disclosed to third parties; [4] and – The process for consumers to be provided with written or electronic notification of case management actions and recommendations; [4] and © 2015 URAC 28 Consumer Education and Engagement CM 8 – Case Management Disclosure (continued) To promote consumer awareness regarding the availability of: – A complaint process and method(s) by which to access it; [4] and – Case management services and how to access clinicians accountable for coordinating care. [M] © 2015 URAC 29 Staff Training and Qualifications CM 9 – Case Manager Competencies The organization facilitates education for case managers to promote expertise and proficiency to remain current in case management practice. Such education includes: Information specific to support case management practice that address: – – – – Nationally-recognized standards for case management practice; [4] Cultural and linguistic competence for the populations served; [4] Ethical code of conduct; [4] and Community resource research skills; [3] © 2015 URAC 30 Staff Training and Qualifications CM 9 – Case Manager Competencies (continued) Access to information and requirements specific to the benefits program, clinical and payer populations served to include the following, if applicable: [4] – – – – Dual eligibility; Commercial plans; Public programs (such as Medicare and Medicaid); and Workers’ compensation; and Identification and reporting of incidents and/or unusual occurrences such as domestic violence, neglect, abuse, and/or behavioral health issues to the appropriate entity. [M] © 2015 URAC 31 Staff Training and Qualifications CM 10 – Case Manager Staff The organization establishes documented procedures to ensure that Case management support staff (clinical staff and non-clinical administrative staff): – Have clearly-defined roles and responsibilities; [4] – Have training appropriate to defined roles and responsibilities; [4] – If they are non-clinical administrative staff, then they are restricted from performing clinical activities; [M] and – Have immediate access to a case manager or clinical supervisor; [M] © 2015 URAC 32 Staff Training and Qualifications CM 10 – Case Manager Staff (continued) The case manager: – Will retain accountability for the case management plan and process; [4] and – If interacting directly with support staff, provides input on the performance of support staff to their supervisor; [4] The case manager, when providing on-site/field case management services will: – Carry a picture ID with full name and name of the organization/company; [2] and – Follow applicable hospital/facility procedures, to include checking in with designated hospital/facility personnel; and [4] Case management staff is required to provide their name, role, and responsibility regarding the case management program for identification purposes during consumer interactions. [2] © 2015 URAC 33 Staff Training and Qualifications CM 11 – Case Manager Qualifications The case manager position requires: A current, unrestricted license or certification to practice a health or human services discipline in a state or territory of the United States that allows the health professional to independently conduct an assessment as permitted within the scope of practice of the discipline; [M] or © 2015 URAC 34 Staff Training and Qualifications CM 11 – Case Manager Qualifications (cont.) In the case of an individual in a state that does not require licensure or certification, the individual must have a baccalaureate or graduate degree in social work or another health or human services field that promotes the physical, psychosocial, and/or vocational well being of the persons being served that requires: [M] – A degree from an institution that is fully accredited by a nationallyrecognized educational accreditation organization; – The individual must have completed a supervised field experience in case management, health, or behavioral health as part of the degree requirements; and – URAC-recognized certification in case management within four (4) years of hire as a case manager; © 2015 URAC 35 Staff Training and Qualifications CM 11 – Case Manager Qualifications (cont.) Two years full-time equivalent providing direct clinical care to the consumer; [4] and If directly supervising the case management process, achieves URAC-recognized certification in case management within three (3) years of directly supervising the case management process. [4] © 2015 URAC 36 Staff Training and Qualifications URAC Recognized Certification in Case Management © 2015 URAC 37 Discussion Questions Is it okay for a job description to be met at 80 percent to receive full credit? How do you monitor your case loads? What is your current case load? What does scope of your licensure means? What is an acceptable CM certification for CM 4? © 2015 URAC 38 Case Management Assessment and Plan CM 12 – Assessment Categories The organization implements written policies and/or documented procedures requiring case managers to conduct an assessment of each consumer. During the initial or subsequent assessments, for each consumer, the case manager assesses and documents: Current health status; [3] Clinical history, including medications; [3] Treatment plan; [3] Resources required to meet immediate needs for healthcare; [3] Care coordination needs, including transitions of care; [3] Safety concerns; [3] Behavioral health status, including psychosocial aspects; [3] © 2015 URAC 39 Case Management Assessment and Plan CM 12 – Assessment Categories (continued) Social service and support needs; [3] Consumer’s input, including perception of needs such as healthcare needs and social services and supports; [M] and The need for culturally and linguistically-appropriate services reflecting individual needs, if applicable. [2] © 2015 URAC 40 Case Management Process REMEMBER! Not all categories listed on the standard will be necessarily pertinent to the organization’s population. The policy must address what categories are relevant. The policy must address what categories must be assessed at initial contact and what categories can be assessed during subsequent contact. If a category is not assessed when required, the case manager must document the reason for the deferment. The standard/element will be considered “NOT MET” if, for a closed case, the category is never assessed – even to document why it was not pertinent or relevant to the case; OR if deferred for assessment and no follow-up was documented. © 2015 URAC 41 Case Management Assessment and Plan CM 13 – Medication Safety Assessment As part of the case management assessment, the organization promotes medication safety whereby the clinician educates, assesses, and documents the consumer, family and/or caregiver’s: Understanding (knowledge) of current medications; [3] Use (adherence) of current medications, including experienced side effects; [3] Access to and use of current medication list (paper or electronic); [3] Sharing of current medication list with treating provider(s); [3] Need for medication reconciliation; [3] and Need for medication therapy management services. [L] © 2015 URAC 42 Case Management Assessment and Plan CM 14 – Consumer-Centered Case Management Plan The organization implements a collaborative process for developing consumer-centered plans such that written policies and/or documented procedures require that every case management plan: Is facilitated and documented by a case manager: – In collaboration with the consumer and/or individual(s) chosen by the consumer and members of the healthcare team; [4] – As needed in consultation with health professionals with expertise in the areas addressed by the consumer-centered case management plan; [4] and – Who periodically updates the consumer-centered case management plan based upon changes in the consumer's needs; [4] and © 2015 URAC 43 Case Management Assessment and Plan CM 14 – Consumer-Centered Case Management Plan (cont.) Identifies: – – – – – Measurable short-term goals; [4] Measurable long-term goals; [4] Interventions with timelines to meet short and long-term goals; [4] Resources to be utilized; [4] Timeframes for re-evaluation and response to services (follow-up); [4] and – Collaborative approaches to be used for the purpose of facilitating the case management plan as well as the coordination and transitioning of care (including family, caregiver, physician, and other healthcare provider participation). [4] © 2015 URAC 44 Care Coordination CM 15 – Care Coordination As part of the case management process, the organization establishes written policies and/or documented procedures that address timely and appropriate coordination of services and supports for consumers. In order to facilitate these activities, the organization will assess the need for: Coordination of follow-up services for evaluation and management, including referrals for: – – – – Health care services; [3] Behavioral health care services; [3] Social services and supports; [3] Providers; [3] and Locating available community resources, including vendors to assist with consumer-identified and healthcare-related issues. [3] © 2015 URAC 45 Transition of Care – Optional Standards for Designation © 2015 URAC 46 Transitions of Care CM 16 – Transitions of Care Planning To promote effective transitions of care, the organization implements written policies and/or documented procedures that address: The criteria used to identify consumers eligible for transitional care services, including the situations that trigger a review and possible modification of that criteria; [M] A formal process to proactively identify and track transitions of care; [M] © 2015 URAC 47 Transitions of Care CM 16 – Transitions of Care Planning (continued) Where applicable, guidelines for care coordination and managing transitions of care across different: – Locations/care settings; [2] – Levels of care; [2] and – Providers; [2] and Consumer engagement activities used to reinforce and achieve selfmanagement goals, to include the consumer’s use of: – Individualized healthcare tools; [3] and – Personal health records. [L] © 2015 URAC 48 Transitions of Care CM 17 – Care Transition: Information Transfer and Requirements To promote effective transitions of care, the organization ensures the timely transfer of relevant healthcare information across entities. To meet that goal, the organization establishes and implements: Criteria to determine what data is relevant for care transitions; [M] Protocols to verify clinical staff and non-clinical administrative staff accountable for coordinating care transitions; [M] Protocols for data-sharing and information exchange, including timelines for that exchange; [2] © 2015 URAC 49 Transitions of Care CM 17 – Care Transition: Information Transfer and Requirements (continued) A process specific to care transitions from a facility, such that written care transition summary information is provided before or at the time of transition to the: – Consumer, family and/or caregiver; and [M] – Provider and/or other health professional; and [M] Uniform document(s) for care transition summary information. [4] © 2015 URAC 50 Transitions of Care CM 18 – Transition of Care Follow-up To ensure continuity of care and prevent facility re-admissions, the organization conducts proactive outreach to facilitate effective transitions of care. To achieve these goals, the organization implements: A clearly-defined plan for consumer: – Outreach; [3] – Goals; [3] and – Monitoring; [3] and A process specific to care transitions from a facility for conducting: – Initial outreach within two (2) calendar days; and [M] – Subsequent outreach within fourteen (14) calendar days. [M] © 2015 URAC 51 Case Management Standards that are Not Applicable to Workers’ Compensation CM 3(c) – Consumer Involvement in Shared Decision-Making: Consent for workers’ compensation case management programs is optional because, in many states, consent for case management is assumed under a state’s workers’ compensation law. CM 16 – Transitions of Care Planning: Is not applicable to workers’ compensation and is an optional standard for organizations wishing to obtain a separate transitions of care designation. CM 17 – Care Transition: Information Transfer and Requirements: Is not applicable to workers’ compensation and is an optional standard for organizations wishing to obtain a separate transitions of care designation. CM 18 – Transitions of Care Follow-Up: Is not applicable to workers’ compensation and is an optional standard for organizations wishing to obtain a separate transitions of care designation. © 2015 URAC 52 Applicable Case Management Standards (except when the consumer is attorney-represented and exparte communication is not allowed or when state regulations prohibit consumer collaboration by case managers) CM 6 – Consumer Motivation and Engagement CM 7 – Consumer Education CM 12 – Assessment Categories: Care coordination and referrals may also be limited to the injured worker’s claimrelated injury and, therefore, subsequent assessments may not include areas unrelated to the injury/claim. CM 14 – Consumer-Centered Case Management Plan: The injured worker does not always have an option to choose who their medical treatment provider will be as their care may be directed by regulatory requirements. CM 15 – Care Coordination: Injured workers may have limited rights and other stakeholders (e.g., claims examiners, attorneys, etc.) may impact decision making. In some states, care coordination may be limited to the injured worker’s injury as identified in the claim. © 2015 URAC 53 On-site Review Discussion Questions Does URAC specify assessment categories for the assessments conducted by the case manager? What is the look-back period for selecting files? How many cases will be reviewed during the on-site review? Do case records need to be printed for the file audit? How do accreditation reviewers decide who to interview during the onsite? Does the senior clinical staff person have to be present during the on-site? © 2015 URAC 54 Question and Answer Session © 2015 URAC 55 URAC Education Programs, Events and Resources © 2015 URAC 56 © 2015 URAC 57 URAC Education Programs and Events Access your CEUs through Prime 1. Go to http://primeinc.org/ credit 2. Enter Pharmacy Core program code: 67LV1523 © 2015 URAC 58 Standards Interpretation – Submit an Inquiry © 2015 URAC 59 Thank you! URAC 1220 L Street, NW, Suite 400 Washington, D.C. 20005 Phone: (202) 216-9010 Fax: (202) 216-9006 www.urac.org Visit URAC’s Resource Center to submit your Standards Interpretations question. For more information go to: www.urac.org/education © 2015 URAC 60