Presentation Transcript

1. Care Plan Audit Review

   Crossing the “t”s, Dotting the “i”s: A review of the 2014 care plan audit review for audit dates January 1 – December 31, 2013 and changes for the 2014 audit year
2. Audit G0al To facilitate an interdisciplinary, holistic, and preventive approach to determine and meet the health care and supportive service needs of members
3. Sources of Evidence Comprehensive care plan Health Risk Assessment (HRA) tools such as the Long-Term Care Consultation (LTCC), PraPlus, PraPlus with additional questions, Developmental Disability (DD) waiver screening, MnCHOICES, and the HRA Case notes to supplement the care plan Home and Community Based Services (HCBS) (Managed Long-Term Services and Supports [MLTSS]) service plan Customized Living tool and plan Community Alternatives for Disabled Individuals (CADI), DD, and Brain Injury (BI) waiver plans Group home/adult foster care plans of care Targeted case management plans
4. Desired Outcomes Outcomes are designated as met, not met, or not applicable. Some outcomes have multiple parts, such as this outcome for a new member: The assessment is completed within 30 calendar days of enrollment; and The assessment results are included in the care plan; and All areas of the assessment have been evaluated and documented. – Or – If assessment not completed within 30 days – Document
5. Annual HRA All members who have been a member of PrimeWest Health for more than 12 months must have an annual reassessment. It must be completed annually (more often if needed). Date the annual assessment is completed must be within 12 months (2013)/365 days (2014) of the previous assessment. If not, why? Member was hospitalized, member cancelled appointment, member did not show up, unable to reach the member. Document the reason and what you did in response. For example: Member was hospitalized on February 14, 2014 and remains hospitalized. During transition of care planning, we rescheduled the LTCC for xx/xx/2014. We discussed the importance of an assessment with the member, and we have set up an appointment for xx/xx/2014 Member has refused to schedule an assessment time. I will follow-up with the member in XX days and reoffer the assessment. Results of the assessment are included in the care plan.
6. The Care Plan Interdisciplinary Care Team (ICT) – who and when. The care plan must be completed within 30 days of the assessment. If it was not, why? The care plan includes documentation of services that are essential to the health and safety of the member. The care plan identifies of any risks to health and safety and plans for addressing those risks. Member is forgetful, the oxygen is left on the lamp stand Member’s house has no pathways Member is driving unsafely Member is not remembering to take medications If member refuses recommended care or services: A personal risk management plan is evidence of a discussion between care planner and member about how to deal with situations when support has been refused. It shows the member has made an informed choice.
7. The Care Plan1 The care plan must accommodate the specific cultural and linguistic barriers and any disability conditions of the member. A barrier analysis includes issues such as language or literacy, lack of or limited access to reliable transportation, a member’s lack of understanding of his/her condition, a member’s lack of motivation, financial or insurance issues, cultural or spiritual beliefs, visual or hearing impairments, and psychological impairment. Document that issues were assessed, even if no barriers were identified. PrimeWest Health will review for the barrier element, but it will not count in the 2013 audit outcomes. It will be on the 2014 audit protocol. A cultural need, preference, or limitation addresses the following: Health care treatments or procedures that are religiously or spiritually discouraged or not allowed Family traditions related to illness, death, and dying Disabilities or issues that might affect a member’s preferences
8. The Care Plan2 Care plan goals must be identified, prioritized, measurable, outcome-based, and time-limited. The care plan is personalized to a member’s specific needs and identifies the following: Prioritized goals Consider the member and caregiver needs and preferences determined by the ICT. PrimeWest Health will review for the goal element, but it will not count in the 2013 audit outcomes. It will be in the 2014 audit protocol. Document reassessment and adjustment of the care plan and its goals Interventions These are the member’s self-management activities to manage his/her health They include preferences and desired level of involvement Resources to be utilized, including the appropriate level of care Planning for continuity of care, including transition of care and transfers Collaborative approaches to be used, including family participation Time frame for re-evaluation: How are you going to follow-up and when?
9. The Care Plan3 The care plan must document how essential services will be provided in the case of an emergency. For example: Staff not showing up, power outage Community-wide disaster such as extreme weather-related conditions (floods, tornados, snowstorms/blizzards) Who are you going to contact or who will check on you The care plan must include information on annual preventive exams. Documentation that substantiates a conversation was initiated with the member Documentation that the member completed the exams If the member is new and on Medicare, you must have and document the conversation within 30 days of enrollment The care plan must include Advance/Health Care Directives. Documentation that substantiates the following: Conversation occurred Member refused Culturally inappropriate Already completed
10. The Care Plan4 Member choices for HCBS/MLTSS Choice noted in LTCC Completed and signed care plan Member given a copy of their care plan Community services and support section If attempted but not completed, document why Caregiver support plan Fast Track Intervention Strategies (FTIS) for Special Needs BasicCare (SNBC)/Prime Health Complete members Member is enrolled with Assertive Community Treatment (ACT) Ask Mayo Clinic nurse line Coordination of care management services with other case managers/care coordinators/ICT
11. Signed Signature Page The signed signature page is the final documentation that the member has/will receive his/her care plan, was involved in its development, and has accepted care management. Appeal rights information is provided to the member. This will be on the PrimeWest Senior Health Complete 2014 audit protocol and will become part of the PrimeWest Senior Health Complete signature page. Data privacy information is provided to the member. This will be on the PrimeWest Senior Health Complete 2014 audit protocol and will become part of the PrimeWest Senior Health and Prime Health Complete/SNBC signature pages.
12. Remember All results of the LTCC need to be evaluated and documented. If not a concern, document as such or as “a history of” All fields relevant to the members program need to be completed with pertinent information or noted as not applicable or not needed. The assessments must be completed in the specified time frames or noted otherwise. Include documentation of dates and follow-up. Include equipment back-up plan. If items are attempted and not completed, document it.