case management documentation - texas
Post on 28-Mar-2022
1 Views
Preview:
TRANSCRIPT
MCM ACUITY DOCUMENTATION TO MEET THE STANDARD
• The two monitoring indicators we will focus on here are:
• Percentage of MCM clients with documented evidence of an acuity level using an
approved acuity scoring tool with the comprehensive assessment in the primary record
system
• Percentage of MCM clients with documented evidence of review of acuity at a
minimum of every three (3) months to ensure acuity is still appropriate level for the
client’s needs
UPDATED ACUITY DOCUMENTATION
• How does this look in monitoring?
• Acuity for clients accessing MCM services, at a minimum, should be updated every
three (3) months, right?
• If the client acuity was scored in January 2019, when would the monitoring team expect
to see an updated acuity tool?
• Answer: April 2019
• If the client acuity was scored in January 2019, and the client declined MCM services,
when would the monitoring team expect to see an updated acuity tool?
• Answer: So long as it was documented that the client decline services, the monitoring team
would not expect to see an updated acuity tool
ASSESSMENT OF MCM PRIORITY NEED• MCM Assessment
• MCM Performance Measure in the Standard:
• Percentage of clients who access MCM services
that have a completed initial comprehensive
assessment within 30 calendar days of the first
appointment to access MCM services and
includes all required documentation in the
primary client record system.
ASSESSMENT OF NMCM PRIORITY NEED
• NMCM Performance Measure in the
Standard:
• Percentage of clients who access NMCM
services that have a completed
assessment within 30 calendar days of
the first appointment to access NMCM
services and includes all required
documentation.
MCM ASSESSMENT EXAMPLE
• This is one example of a comprehensive initial assessment entered in ARIES:
COMPREHENSIVE ASSESSMENT EXAMPLE
• What about this assessment? Does it provide detail to determine client needs? Would
this client require MCM or NMCM services?
CREATING A CARE PLAN• Elements of a Care Plan (minimum standards):
• Developed Care Plan (MCM and NMCM) Monitoring Indicator:
• Percentage of MCM or NMCM clients with documented evidence that a Care Plan was developed and
contains all of the following:
• Problem statement/need
• Goal(s)
• Intervention (tasks, referral, service delivery)
• Responsible party for the activity
• Timeframe for completion
CARE PLAN EXAMPLES
• The following example did not met the monitoring standard for a developed care
plan. Can you pick out why?
CARE PLAN EXAMPLEBelow is an example of a initial developed Care Plan. Does this meet the Standard
requirement for minimum documentation?
UPDATING CARE PLANS• MCM Monitoring indicator:
• Percentage of MCM clients with documented evidence of an updated care plan with
outcomes and that has been revised or amended in response to changes in client life
circumstances or goals, at a minimum, every six (6) months.
• NMCM Monitoring indicator:
• Percentage of NMCM clients with documented evidence that the care plan was
developed and/or updated two or more times in the measurement year.
• How are these indicators monitored? What documentation do we need?
UPDATED CARE PLAN
• Now it’s your turn! Does this care plan meet the indicator for an updated care plan?
CASE NOTES
• Case notes provide the detail and background for the assessment/reassessment of
the client’s needs. In addition, case notes tell the story from day 1 to day ??? of all
activities completed both by the case manager and by the client to help achieve the
tasks and goals in the care plan.
• Client education is an integral part of ensuring clients’ knowledge increases
throughout the course of providing case management services.
• Let’s start with the education requirements in the DSHS MCM Service Standard.
MCM SERVICES EDUCATION DOCUMENTATION
• The MCM monitoring indicator for education provided is listed below:
• Percentage of MCM clients with documented evidence of education (appropriate to
age) provided to each client which includes all of the following:
• Medication adherence
• HIV disease process
• Risk reduction/prevention strategies, including substance abuse
• Nutrition
• Oral Health
• There are several ways a case manager can meet this indicator in their
documentation during a monitoring review……let’s explore some examples…..
CASE NOTE EXAMPLE - EDUCATION
• ARIES documentation of education provided during the assessment phase:
MONITORING NOTE
In areas/regions where Referral for Health Care Services is not a funded service and
case managers are limited to only entering service units based on their job title, if a
client intake is completed and the client does NOT require or declines case
management assistance, enter the service unit as either:
Case Management (non-medical)>Intake-No CM or
Medical Case Management (including treatment adherence)>Intake-No CM
ROLE PLAY
• Have an example of a few potential clients
• Have case managers within their tables determine who will be the ‘client’
• Document an acuity based on the case managers’ interview with the client
• Complete an assessment
• Create a care plan
• Go around the room and have volunteers discuss their acuity and care plan
documentation, how they determined what the client needed, how they interviewed,
questions asked, how did they determine MCM vs NMCM, how did their care plan
look
top related