Download Case Management

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
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3
Presenter
Sandi Greenawalt RN
MCHA-Wellness Promotion CCM, CCP, CPHQ
Six Sigma Green Belt
Manager Accreditation Services
9/10/2015
© 2015 URAC
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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
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“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
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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
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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.
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AccreditNet Application Instruction Booklet
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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
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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
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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
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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
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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
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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
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Crosswalk Table
Case Management v5.0 and v4.1
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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]
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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
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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]
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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]
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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]
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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.
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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]
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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]
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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]
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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]
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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]
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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
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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]
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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]
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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]
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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]
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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]
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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
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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;
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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]
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Staff Training and Qualifications
URAC Recognized Certification in Case Management
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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?
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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]
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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]
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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.
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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]
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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
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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]
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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]
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Transition of Care –
Optional Standards for Designation
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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]
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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]
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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]
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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]
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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]
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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.
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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.
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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
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Question and Answer Session
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URAC Education Programs, Events and Resources
© 2015 URAC
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© 2015 URAC
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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
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Standards Interpretation – Submit an Inquiry
© 2015 URAC
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Thank you!
URAC
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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
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