Components of Case Management For Health Care Providers

1. Components of Case ManagementFor Health Care Providers (Please use the “Slide Show” mode in PowerPoint)

2. Case Management Training Goals • The primary goal of case management training is to help practitioners work more effectively with clients needing a diagnostic work-up and/or treatment. By enhancing case management skills, practitioners will be better able to assess and work through barriers to the client receiving care, locate hard-to-reach and/or non-compliant patients, and improve their patient tracking systems within their facilities. • Additionally, this training teaches Sage Screening Sites how to obtain reimbursement for providing case management services on Sage patients.

3. History of the Sage Screening Program • The late 1980s saw a confluence of forces which ultimately brought about the creation of a national program to provide breast and cervical cancer screening to underserved women. The efficacy of mammography and the need for a greater focus on women’s health issues became a focus of advocacy groups whose petitioning ultimately prompted congress to put money towards screening for low-income, uninsured or underinsured women. The outcome of this activism was the 1990 Breast and Cervical Cancer Mortality Prevention Act which authorized the establishment of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) through the Centers for Disease Control (CDC).

4. History • As a result of this federal legislation, Minnesota was chosen as one of the four original states given money to screen low-income, uninsured or underinsured women for breast and cervical cancer, thereby creating the Minnesota Breast and Cervical Cancer Control Program (MBCCCP). The name was changed to the Sage Screening Program in 2004. The first patient was screened in January 1992 and by 2008, over 107,000 women had been screened, over 168, 000 mammograms had been done, and 174,000 pap smears had been performed. From these tests, over 1,200 cancers have been detected.

5. Case Management in Sage (1) The federal legislation which authorized the NBCCEDP did not specify case management as a program component in l990, and therefore, did not fund this activity. States and screening sites were expected to ensure that women screened through the program would receive the necessary diagnostic and/or treatment services, but were not funded to do so. This created great challenges to those involved in the screening, diagnosing, and treating of the patients, as well as the patients themselves.

6. Case Management in Sage (2) • Fortunately, a 1997 CDC-funded study of follow-up and treatment issues in the NBCCEDP confirmed what had been found in Minnesota: major problems existed in getting women the needed diagnostic and treatment services. Minnesota was not alone in facing the challenges of finding payment sources for follow-up care. • As a result of this study, a 1998 amendment to the NBCCEDP included case management as a component of the program, thereby allowing funding of this activity. This enabled each state to establish a plan for paying sites not only for performing tests on women, but also for working with these women to help them get the necessary diagnostic and/or treatment services.

7. Case Management Demonstration Sites • With the inclusion of case management nationally as a program component, Sage looked to find how best to provide case management services in the Minnesota program. • In March of 2000, four case management “demonstration sites” were funded. The sites selected were high volume screening sites that could benefit from dedicated resources for case management. In each of these sites, a case manager was funded to provide case management services.

8. Case Management Demonstrations Sites: Goals These demonstration sites had the following goals: • Reduce the time from screening to diagnosis • Reduce the time from diagnosis to treatment • Reduce the number of patients “lost to follow-up • Increase re-screening rates

9. Case Management Demonstration Sites, Outcome • Focusing on case management at these sites did, in fact, improve time frames for providing services to women. • As a result, several one day training sessions on case management were held around the state in the fall of 2001. • These trainings were a way to increase awareness that Sage would pay sites to do case management, and to educate providers on how to offer case management services and how to bill the program for providing these services. • Funding of case management went program-wide late in 2001.

10. Purpose and Goals of Case Management in Sage • The purpose of case management is to ensure that women with abnormal screening results, or a diagnosis of cancer, receive appropriate (per ASCCP and the Sage “Primer for Evaluation of Common Breast Problems”) diagnostic and/or treatment services in a timely manner. • Goals are: to reduce the time from screening to diagnosis; reduce the time from diagnosis to treatment; reduce the number of women who are “lost to follow-up” and to increase the number of women who are re-screened.

11. The Case Management Society of America defines case management as “a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost effective outcomes.” Case management is a process which works to reduce the barriers that keep women from receiving the needed diagnostic and/or treatment services. Case Management definitions:

12. Case Management DefinitionKey Words • Collaborative process: health care providers, possibly social service providers, and the client are all working together to obtain the needed services • Communication: involves both working with the client to ensure that she understands and is aware of the need for the recommended care, and to assess potential barriers to the patient receiving the care. Communication also refers to the appropriate sharing of information between medical providers, and possibly social service professionals. • Resources: being aware of financial and medical resources, as well as resources for transportation, child care, translation services, etc., within a community and being able to link the client to these resources.

13. Key components of Case Management • Assessment • Planning • Coordination • Monitoring • Evaluation

14. Assessment • Assessment is the first step in the case management process. • An assessment can be done on any Sage patient with a breast or cervical abnormality* who has not already received the recommended care. Once you have identified a woman needing further care (either by a referral in the clinic or by review of results), the assessment can be completed in person, or by telephone. * abnormalities include: • Breast exam suspicious for cancer, • Mammogram results of “Assessment Incomplete,” “Suspicious” or “Highly Suggestive of Malignancy” • Pap Smear results of LSIL, HSIL AGC, ASC-H, Adenocarcinoma, Squamous Cell Carcinoma, or a positive high risk HPV test requiring colposcopy • Any Colposcopy

15. Step 1: Assessment • The assessment process has two components: • Interviewing the woman to ensure that she is aware of the care she needs to obtain • Determining barriers preventing the woman receiving care. • Good communication skills are essential to a good assessment.

16. Assessment: Communication Effective communication involves: • Developing trust. Let the client know that you would like to help her obtain the care she needs. Allow the client the option of declining your involvement. • Using open-ended questions. How, when, what, where questions elicit more valuable information than yes/no questions. • Validating the information you receive. Letting the client know that you’ve heard what she’s telling you by summarizing and re-stating the information she’s provided. • Using active listening skills. Observe the client’s non-verbal as well as verbal communication. Make sure that you’re not communicating anything negative through your body language.

17. Assessment: Communication Barriers to Communication • Time Constraints: Make sure you have enough time to spend on the assessment; being rushed will hamper effective communication. • Privacy and confidentiality: Ensure your client is in a place to talk freely and assure her your interactions are confidential. • Language: Use an interpreter if you don’t speak the same language as the client. Target your discussion to the client’s level of understanding (do not talk above or below the client). • Interviewer’s values and belief system: Leave your values and beliefs out of the interview: a judgmental attitude will derail communication. • Non-verbal messages: Just as the interviewer observes the client’s non-verbal communication, the client will observe yours. Make sure you’re not (non-verbally) sending the wrong message.

18. Assessment • Once you’ve established trust with the client and made sure that she wants your involvement, the assessment can take place. • The assessment is the process by which you determine if the client is aware of what type of care she needs, and how she can go about obtaining this care, and if barriers exist which will keep her from obtaining this care. • Many of the women screened through Sage have significant barriers to obtaining care. Sage clients are women who are uninsured or underinsured; therefore, financial barriers to obtaining expensive testing and/or treatment often exist. In addition, since these women are lower income, many other barriers to care can exist. • A comprehensive assessment evaluates the medical, financial, psychosocial, and environmental issues in a client’s life for barriers that will affect her accessing care.

19. Assessment:Barriers to Obtaining Care • Medical: past medical history, current medication and treatments, disabilities, history of abuse, functional status • Financial: insurance (i.e., unmet deductible, co-pays and lack of money), employment (unable to get off work), costs related to transportation/child care. • Psychosocial: family/support system, cultural issues (beliefs about disease/illness, use of faith healers, modesty), language, fears, emotional/motivational, knowledge • Environmental: weather, health care facility accessibility, daily priorities, family needs (child/elder care)

20. Step 2: Planning • Planning involves: • Using the information collected in the client assessment to identify barriers to care • Working with the client to develop a plan to overcome the identified barriers so she can obtain the needed care. • Effective planning is dependent on your awareness of existing resources in your community that will help enable your client to receive care.

21. Planning • Barriers to receiving care can be addressed and often eliminated during the assessment and planning part of case management. • A case manager is often in a position where he/she can provide more information to the client than was given by the provider. A common barrier to receiving care is fear, which can often be lessened or eliminated by providing the client with more specifics on the medical condition involved and greater detail on what the recommended testing/treatment involves. Through providing more information, this type of interaction can often help the client follow through with the recommended care by lessening her fear of the unknown.

22. Planning • As a case manager you can assist a client in thinking of options for addressing barriers. For example, you may be able to encourage her to think of someone who can give her a ride to an appointment, or who can provide child care while she goes to an appointment. • Additionally, you can provide her with information about resources that exist in your community and through the Sage Program to assist with financial/medical needs.

23. Step 3: Coordination/Implementation • Coordination is the process by which you use the knowledge you’ve obtained from your assessment and help the client access care. Coordination involves the use of resources, referrals and documentation. • When the patient develops a plan to get the needed care, make sure you have an arrangement to get back in touch with her to find out the outcome (and to check back if she doesn’t follow through on the appointment).

24. Coordination: Resources A number of resources exist to enable women screened through Sage to secure diagnostic and/or treatment services. In addition to resources identified by Sage, there may be additional resources in your community. For example, some physicians are willing to do charity care, and some civic organizations and churches raise money for charitable causes or provide transportation to those in need. Some hospitals have charity dollars available; however, information about these funds is often not publicized and need direct inquiry.

25. CoordinationResources: Financial • Most breast diagnostic services, as well as colposcopy for follow-up of cervical abnormalities, are covered through the Sage Program. • Other resources exist on a county-by-county basis and can be accessed through the Sage Financial/Medical Resource Handbook (available by calling the Sage Program at (651) 201-5600.

26. Coordination: ResourcesMA-BC • MA-BC is a form of Medical Assistance specifically for Sage patients needing treatment. • To qualify for MA-BC, a woman needs to: • Have no insurance, or • Not be covered by any “creditable” insurance • Be under age 65 • Have received some of her screening services through Sage • Need treatment for breast or cervical cancer or a precancerous cervical lesion • If she has an immigration status that qualifies her for MA, proof of US Citizenship, and has a social security number, she may qualify for a year of coverage under MA-BC.

27. Coordination: ResourcesMA-BC • To apply for MA-BC, a patient needs: • An MA-BC application • A copy of her Sage Visit form • Proof of citizenship or National Status (passport or driver’s license and birth certificate) • The completed application, a copy of her Sage Visit form, and proof of citizenship goes to her county social services for processing. • Women generally obtain MA-BC within a week.

28. Coordination: ResourcesMA-BC: Presumptive Eligibility • Presumptive Eligibility provides an immediate coverage option for women who appear to meet the basic eligibility criteria for MA-BC (no insurance, under age 65, and need treatment for breast or cervical cancer or precancerous lesion). It is useful in providing coverage for women who need to begin treatment immediately. • Since the determination of presumptive eligibility does not consider citizenship or immigration status, women whose citizenship or immigration status is unknown or uncertain may be eligible. Providers do not need to ask about a patient’s immigration or citizenship status.

29. Coordination: ResourcesMA-BC: Presumptive Eligibility • The clinic where the woman was screened can grant Presumptive Eligibility. Prior to granting presumptive eligibility, the MA-BC Presumptive Eligibility training and certification process must have been completed by the person granting Presumptive Eligibility. This training is available on the Sage website at MNSage.com. • The woman needs to complete an MA-BC application which needs to be sent with her Sage Visit form to the county for processing. The patient will then be eligible for Medical Assistance for approximately one month. Any services provided during that one month timeframe will be covered by MA.

30. Coordination: Resources • A limited number of taxi vouchers and bus tokens are available to women in the Twin Cities area. • Women living in greater Minnesota may be able to obtain transportation through civic organizations or through some medical providers. • Limited interpreter services are available to Sage patients, again dependent on the patient’s home location. Call Sage at (651) 201-5600 for more information on these resources.

31. Coordination: Referrals • With a working knowledge of the resources available for your client, the next step is often making the referral. This process involves routing information to the site to which the patient has been referred, ensuring that the patient has the information she needs to access care at that site, and then following up to ensure that the appropriate care is received.

32. Coordination: Referrals • Having a clinic referral form helps facilitate the transfer of information between your facility and the diagnosing/treating site. The referral form should either be sent with the patient, or sent to the facility before she arrives for care. • Once the patient has received care, your facility should be sent information concerning the results of any testing completed and documentation of treatment received by the patient.

33. Locating and working with “hard to reach” patients • In providing case management services you will encounter situations in which you have a patient needing care who you are unable to reach. Likewise, you will find patients who are aware of the fact they need a diagnostic or treatment procedure and fail appointments for care. The following slides will offer suggestions for working with these patients.

34. Contacting hard-to-reach/locate patients (1) • Reaching Sage patients to notify them of results and/or to offer case management services can be challenging. The women are lower income and may move from place to place, and phone numbers may change or be disconnected. Furthermore, women may be unreachable during normal working hours. • To reach patients by phone, make phone calls at various times of the day (i.e., early morning or late afternoon or evening). Numerous attempts at reaching a patient should be made, on varying days of the week and at various times of day. • If possible, phone contact should be attempted on the weekends. This is the best time to reach many women.

35. Contacting hard-to-reach/locate patients (2) • If you are phoning and reaching someone other than the patient at the listed number and you are told she’s not home or no longer lives there, try open-ended questions to find out how best to reach the patient (rather than yes/no answer questions). • For example, “what is her new phone number?”, “when will she be home?”, “what time is best for me to reach her?” Open-ended questions tend to elicit more usable information. • If you are unable to locate a patient, you can try the white pages or the internet for a telephone number and address of the patient.

36. Contacting hard-to-reach/locate patients • If you have tried repeatedly at varying times to reach a patient by phone and have been unsuccessful, or if her phone number is no longer active, you should attempt contact either in person or by mail. • While doing a home visit is not an option in most clinic settings, it is one of the best ways to reach a patient, and to stress to her the importance of getting the needed care. • Mail can initially be sent via regular mail, but (if no response) should be followed up with a certified letter before a patient is considered lost to care. A certified letter again stresses the importance of obtaining care to the patient, and also provides documentation of your efforts.

37. Working with “hard to reach” patients When you reach a patient by phone, be sure to: • Introduce yourself and explain your role • Ensure the patient can talk privately • Speak slowly and clearly • Make sure the patient understands your message • Explore barriers to the patient getting care • Develop a plan with the patient for her next steps to obtain care • Arrange a time for your next contact with the patient • Summarize your call with the patient • Document your efforts Also see slides 15 and 16 in “Assessment” for more suggestions

38. Non-compliant patients (1) • Despite your best efforts, some patients will not get the recommended care. Ideally the case management assessment will uncover potential barriers to the patient receiving care, and hopefully, these barriers can be overcome. However, some patients refuse to get the needed care. • If you talk to a patient after she has failed an appointment, again try to find out the barrier(s) to her receiving the needed care. Again, try to work with her to develop a plan for her to get this care.

39. Non-compliant patients (2) • Ultimately a patient can refuse the recommended diagnostic and/or treatment services. When this happens either by the patient directly refusing to get the care or by her repeatedly failing appointments, try to ensure she’s making an informed decision. • Patients should be made aware of the options/resources for getting care and also made aware of the potential risks if they choose to decline care. Documentation of these discussions should be clear and detailed.

40. Step 4: Monitoring • Monitoring refers to tracking the client on an individual level and tracking the progress of your patient follow-up on a program level. • Regular, consistent monitoring will help ensure timely diagnosis and/or treatment and decrease your lost to follow-up rates. • By having an established referral network and by having a clinic referral form which travels between your facility and the diagnosing/treating facility, you are better able to ensure that your clients receive the recommended care.

41. Monitoring: Tracking Systems • Using a tracking system in your clinic will enable you to better follow your patients with abnormal test results to ensure that patients receive the appropriate follow-up care and are not lost to care. Use of a tracking system also makes it easier to complete the required Sage Abnormal follow-up forms.

42. Monitoring: Tracking Systems • Tracking systems come in various forms: • A computerized system • A manual paper tracking log • A tickler system for following clients • Tracking logs can be used to track normal and/or abnormal results. Sample logs are available through Sage.

43. Monitoring: Tracking systems • For tracking patients with abnormal findings, the system should include patient name, date of birth or medical record number, date of screening, screening tests completed and results, the needed follow-up procedure, the referral facility, and scheduled date of the procedure. • The log should be reviewed weekly and updated when referral information is received back from the outside facility. • Use of such a system will enable you to ensure that your patient gets the needed care, and alerts you when action on your part is needed.

44. Evaluation • Evaluation on an individual level determines whether or not the case management has been effective – were goals met? • Evaluation on system level determines if follow-up and treatment are occurring in a timely manner.

45. Step 5: Evaluation With case management the goal is to have 100% of women with abnormal results receiving timely and appropriate diagnostic and treatment services. Specifically the goals set by the Centers for Disease Control (CDC) are: • Time between abnormal screening result and diagnostics: less than 60 days • Time between diagnostics and treatment: less than 60 days • Reduce the number of women “lost to follow-up” • Increase the number of women getting re-screened

46. Evaluation • On a system basis: • Review individual cases to check for systematic roadblocks • Check timeliness of follow-up • Monitor compliance • Refine case management system as needed

47. Case Management Reimbursement • By completing the appropriate forms, Sage will reimburse you for providing case management services for women with abnormalities (see next 2 slides for forms). • The reimbursement rate for the “Comprehensive Needs Assessment” is $25.00. • The reimbursement rate for completing the “Care Plan” is $75.00 (to be used when barriers are identified and a plan developed to address barriers to needed care).

48. Needs Assessment Form (double click on the form to open it as a PDF to save or print)

49. Care Plan Form (double click on the form to open it as a PDF to save or print)

50. Conclusion The provision of case management services enables health care providers to better ensure that patients receive the recommended diagnostic and/or treatment services. In addition, Sage will reimburse clinics for providing this valuable service to Sage clients.