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Case Management Maintenance

Case Management Maintenance. Galynn Thomas, RN, MSN Children’s Medical Services. Complex Case Management. Low case loads High complexity cases Regular CCS case management. CCSNL Ongoing Responsibilities. Communication & Oversight Monitoring & Maintenance

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Case Management Maintenance

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  1. Case Management Maintenance Galynn Thomas, RN, MSN Children’s Medical Services

  2. Complex Case Management • Low case loads • High complexity cases • Regular CCS case management

  3. CCSNL Ongoing Responsibilities • Communication & Oversight • Monitoring & Maintenance • F-CAP – Authorizations (SARS) • Assurances

  4. Communication & Oversight • Communication • Collaboration • Coordination

  5. Communication Collaboration Coordination • Team work • Partnership • Group effort • Association • Alliance • Relationship • Cooperation • Harmonization • Organization • Management • Synchronization • Bringing Together • Dexterity • Message • Communiqué • Announcement • Statement • Contact • Letter • Email • Phone call

  6. Multidisciplinary SCC Care Coordinator Participant/ Family/ Circle of Support Referring Physician Medical Home CMS Branch Other County CCS staff Communication

  7. Communication • Liaison • Technical assistance • Oversee communication between CC and referring CCS providers to improve PFC practices • Summarization communication in PFC Database

  8. Monitoring & Maintenance • Monthly - Contact Participant/Family Unit • Review F-CAP – • Services requested appropriate • Meet the needs and goals ID – F-CAP • Services are provided (accordance with F-CAP) • Frequency & Duration

  9. Monitoring & Maintenance • Participant/ Family Unit Access to CCS • Resources • Case management • Telephone • Email • Direct contact

  10. Monitoring & Maintenance • Participate PFC Case Management Conference • Telephone • Direct contact • Participant’s home • Agency • CCS • Other facilities

  11. Monitoring & Maintenance • Coordinate Medical Services • PFC Services • State Plan Services – regular Medi-Cal • EPSDT SS • Discharge • Transition • Hospitalizations

  12. Monitoring & Maintenance • Provide Information • Range of Services • Support Groups • Community Services • Provider • Participant, Family & Circle of Support • Inquires

  13. Monitoring & Maintenance • Utilization Management • Evaluate need - services • Authorizations • Review claims paid • Frequency & duration in accordance with F-CAP • Track claims data • Review appropriateness of the provider selected.

  14. Monitoring & Maintenance • Health & Welfare - Federal Assurance (FA) • Monitoring • Health, Safety & Welfare of Participant • On-going risk assessments (FA) by CC • F-CAP • Evaluate risk of abuse, neglect & exploitation • Review psychosocial risk factors

  15. Monitoring & Maintenance • Health & Welfare (cont.) • Document all reported or observed critical events/incidents (FA) • Notify State CMS & send copies • Follow-up – within 30 days • PFC Database

  16. Review of F-CAP • At least every 60 days • Interim – as needed • Services • Goals • Risk Factors • Approve, sign, date, and return

  17. Review of F-CAP • Hospitalizations • Emergency Department Admissions • Respite • Condition Changes – illness trajectory • LOC re-determination • Care Coordinator hours • Therapy hours • Bereavement

  18. Authorizations - SARs • Service limits • Appropriate provider • Special Instructions • PFC, State Plan, and EPSDT Supplemental Services • PFC Database

  19. Role of the Care Coordinator • Coordinate all care • PFC services • State Plan services • Community resources • Collaboration • CCSNL • Participant & family • Providers

  20. Role of the Care Coordinator • Educate and train participants & famiy • Development of the F-CAP • Implementation • Revisions • Goals & services • Home visits • Health, welfare and safety

  21. Role of the Care Coordinator • Accompany to appointments • Maintain records • Correspondence • Conduct monthly interdisciplinary team meetings • Collaboration with CCS Program

  22. Assurances • Level of Care (LOC) • F-CAP revisions – (Service plan development & Delivery) • Service Delivery • Freedom of Choice • Health & Welfare Reporting • Remediation

  23. Other • Transition Plan • Dis-enrollment

  24. Dis-enrollment • Change in health status • Moved • Decline • Hospitalization > 30 days • Loss full scope, no share of cost • Health & Safety issues

  25. Dis-enrollment continued • Compliance with appointments • Enrolled in another 1915c HCBS Waiver • Reached 21st birthday • Transitioned • Passed away

  26. Questions

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