Case Management Policy and Guidance Angela Braithwood, RN, BSN Senior QA Analyst, Case Management...
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Transcript of Case Management Policy and Guidance Angela Braithwood, RN, BSN Senior QA Analyst, Case Management...
Case Management Policy and Guidance
Angela Braithwood, RN, BSNSenior QA Analyst, Case Management
ServicesSkyline Ultd.
Objectives
• Army Case Management Overview• Policy and Guidance • Training and Education Requirements• CMSA and Certification
Army Case Management Model
• DoD– Focus on education and training of CM’s– Inclusion Criteria for MND
• Army – WTU’s and MMC– Based on CMSA Standards– Core competencies– AC-centric: No reserve component model
• National Guard – Varies by State– No official guidance from NGB
Warrior Transition Command
• Where we all started– Initial concept 1994– Initial development 2004– Formalization to WTC in 2005 CPL Kendra Coleman recovers
at Walter Reed National Military Medical Center after losing her left leg in Afghanistan
Applicable Policies for Case Managers
• Case Management Society of America Standards of Practice for Case Management (2010)
• CMSA Core Curriculum for Case Management, 2nd Edition. Suzanne K. Powell & Hussein A. Tahan. Philadelphia: Lippincott, 2008
• Department of Defense TRICARE Management Activity Medical Management Guide Version 3.0
• DTM 08-033, Interim Guidance for Clinical Case Management for the Wounded, Ill, and Injured Service Member in the Military Health System
• DoDi 6025.20, Medical Management• MEDCOM Soldier Medical Readiness Campaign 2011-2016• HQDA EXORD 118-07, Healing Warriors• MEDCOM OPORD 07-55, MEDCOM Implementation of the Army Medical Action Plan
(AMAP)• MEDCOM OPORD 11-20, Patient Centered Medical Home• MEDCOM OPORD 10-66, Medical Management Centers• Comprehensive Transition Plan Guidance
DoDi 6025.20 Medical Management (2006)
• Establishes Medical Management Care Model within the MHS– Utilization Management– Case Management– Disease Management
• Integration and coordination of services– Quality, completeness, and adequacy of total
health care• Outcome Management
DTM 08-33 (July 2012)
• Interim Guidance for Clinical Case Management for the Wounded, Ill, and Injured Service Member in the Military Health System
• Originally released Aug 2009• All-service and component requirements• Basic education, certification, and training• Performance Measures• Documentation/Coding
MEDCOM OPORD 13-25 Nursing Case Management Guidance
• Consolidation of references• Across all components• 5 lines of effort
– CM ID– Training/Education– Performance standards– Quality outcomes/measurement– Strategic communication
Army National Guard Case Management
• Goal – Reduce Medically Not Ready population to maximize number of Soldiers available for mobilization/deployment– PHA/SRP/SRC Support– LOD/IDES Preparation
• Remote Care – Telephonic Case Management– Electronic Database Systems
MEDCOM Soldier Medical Readiness Campaign 2011-2016
• Strategic Level Medical Readiness Plan
• Population Health• ID, Mgt, Health
Promotion• Performance
Measures• Commo
MEDCOM OPORD 10-66, Medical Management Centers
• Closest to what we do at the AC level• Manages MNR Population• Collaboration with Units• Expands use to the RC
Triad of Care
ARNG
OSS
G-1
SM
UNIT
WTU
PCM
NCM
SM
SQD LDR
• AC based on active, clinical CM
• RC based on non-clinical CM
Training and Education
• MHS Learn– Case Management Track– Miliman Ambulatory Care
• Core Curriculum• Army CM Course
– Essentials of Case Management (fee)
Competency AssessmentCase Manager Core Competencies Individual Assessment
Name: ___________________________________ Orientation Start Date: _____________ Completion Date: _____________ Purpose: To standardize the knowledge, skills, and attitudes within the covered professional specialty for all case managers: military, civilian, contractor, and volunteer. Instructions: Pre-Assessment-the case manager will rate each knowledge, skill, or attitude (KSA) from 1 (novice) to 5 (expert) in each box. Following orientation or training, the case manager and preceptor will collaboratively provide a post-assessment.
Competency (Knowledge, Skill, Attitude)
Assessment Method Comments References
(see Appendix A) Pre Post
Foundational/Generic Competencies (consistent for all RNs
CRITICAL THINKING: Demonstrates common nursing skills, knowledge, and attitudes for safe and effective independent nursing practice
Maintains current: RN License; BCLS Certification
Promotes teamwork in a positive manner. Uses ethical, professional, and courteous communication with providers & other departments with no substantiated negative reports. Uses clear concise communication.
Displays values of a DA and DOD employee: Dedications, Integrity, Loyalty to the mission and the unit, Respect, Selfless Service, Honor, and Personal Courage
Personal Accountability: Arrives to work on time and departs as scheduled unless prior approval is obtained. Articulates annual leave policy. Uses Sick Leave as intended by policy. Calls appropriate supervisor when late or sick. Appearance - Clean professional dress. Has hospital name badge and CAC. Completes all assigned tasks by suspense date and time, to include support forms, audits, peer reviews, documentation in databases, memorandums, request for information, and any additional tasks given.
Knowledgeable of American Nurses Association standards of practice for nursing and Case Management Society of America standards of practice for case managers
Demonstrates effective conflict management Demonstrates effective change management
CMSA and Certification
• Army prefers Certified Nurse Case Managers.– AC has CCM course for ANC and DA– No RC course/track yet– Fee-based course for all others
Comprehensive Transition Plan Guidance
• WTU Action Plan for Soldiers• Two Tracks
– Remain in the Army– Transition out of the Army
• Closely tied with MTF’s and PCMH
HQDA EXORD 118-07, Healing Warriors
• Part of the Army Medical Action Plan (AMAP)• Involvement of all Commands (IMCOM, MEDCOM, etc)• WTU’s more widespread (one at each MTF)
– Triad of Care• Soldier and Family Assistance Centers (non-medical)• FRAGOS
– 1: Administrative changes to staff visits, add more specific tasks to Chiefs of Staff, adjust focus
– 2: SFAC setup– 3: Refining WTU screening and entrance criteria– 4: Reserve Component Remote WTU focus
MEDCOM OPORD 07-55, MEDCOM Implementation of the Army Medical Action
Plan (AMAP)• Incorporates HQDA EXORD 118-07 tasks to
MEDCOM• Tasks RMC’s with AMAP deadlines• Streamlines Soldier and Family transition• Sets up TDA and Unit criteria
MEDCOM OPORD 11-20, Patient Centered Medical Home
• MHS Primary Care Model– Part of Access to Care Campaign (2008)
• 100% direct care enrollees in a PCMH NLT FY 2015• Utilization Management• Based on NCQA Standards for PCMH
27 27
MRNCO -assist SM w
records/profiles - BN monthly report
- hand off to CM
Case Manager(CM) -reviews case
- assigns to
Care Coordinator (CC)
CC continues to - assist SM
Case meeting #1 CMD/SS/G1 and CM
Case meeting #2CMD/SS/G1 and CM
CC continues to - assist SM
Case meeting #3CMD/SS/G1 and CM
MRDPNot reached
MRDP ?May get
ONE TIME temp prof extension
per SS
Temp profile written
(issue found by self report, PHA, PDHA,
PDHRA)
0 MO NLT 3 MO NLT 6 MO NLT 9 MO NLT 12 MO
- coordinate w
CM/MRNCO as
needed
- coordinate w
CM/MRNCO as needed
Each case meeting assures: 1) temp profile updated as warranted 2) eval for AD orders for medical care (WTU/RCMC) 3) eval for MMA assignment (option for CMD)
MMPS
Recording Procedures
28
Appropriate profile is issued
Appropriate profile is issued
Temporary Profile is issued
A Permanent 2 Profile is issued
A Permanent 3 Profile is issued
Medical condition is non-duty related
Medical condition is duty related
Soldier is referred to MAR2
Soldier recovers
Soldier is referred to MEB
PEB - Fit Soldier continues with physical disability
processing
Soldier receives Administrative
Discharge
Soldier returns to
duty
PEB - Fit PEB - unfit
Appropriate disability is awarded
Soldier is retained with a change in MOS
LegendMedical ActionMilitary Personnel ActionActive Component ActionMAR2 – MOS Administrative Retention ReviewMEB – Medical Evaluation BoardPEB – Physical Evaluation Board
Soldier meets Retention Standards
Soldier does not meet Retention Standards
A provider determines that a soldier has a medical limiting condition
The Physical Disability Evaluation System
The Physical Performance Evaluation System
Soldier is issued a permanent profile
Soldier is retained in MOS
Soldier is retained with a trial duty
PEB - Unfit
Soldier elects a non-duty PEB