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
Monitoring & MaintenanceMonitoring & Maintenance
• Participant/ Family Unit Access to CCSParticipant/ Family Unit Access to CCS
– ResourcesResources
– Case managementCase management
•TelephoneTelephone
•EmailEmail
•Direct contactDirect contact
Monitoring & MaintenanceMonitoring & Maintenance
• Participate PFC Case Management Participate PFC Case Management ConferenceConference– TelephoneTelephone– Direct contactDirect contact– Participant’s homeParticipant’s home– AgencyAgency– CCSCCS– Other facilitiesOther facilities
Monitoring & MaintenanceMonitoring & Maintenance
• 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
Monitoring & MaintenanceMonitoring & Maintenance
• 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
Monitoring & MaintenanceMonitoring & Maintenance
• 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.
Monitoring & MaintenanceMonitoring & Maintenance
• 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
Monitoring & MaintenanceMonitoring & Maintenance
• 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
Role of the Care CoordinatorRole of the Care Coordinator
• 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
Role of the Care CoordinatorRole of the Care Coordinator
• 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
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
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