Case Management Training

http://dmasva.dmas.virginia.gov/ 1

Department of Medical Assistance Services

Division of Long -Term CareDepartment of Medical Assistance

Services

2012

http://dmasva.dmas.virginia.gov 1


Case Management Training



Goals• Case Management Definition • Case Management Qualifications

• Team approach

• Trends seen by analysts

• Face to face and Quarterlies

• Interruptions and Extensions

• Transfers

• Housekeeping Tips



Goals cont. • Abuse and Neglect

• Quality Management Reviews

• Billing



Case Management (CM)-Definition

Activities designed to assist a child or adult with DD to live in the community by . . .

accessing needed medical, psychiatric, social, educational,

vocational, residential, institutional, and other supports



Case Manager (CM) Qualifications• DMAS Participation

Agreement

• Developmental Disability work experience

• CM and SF can be

the same individual

• Undergraduate degree in a Human Services field

• Cannot be a direct service provider

• Back-up Coverage 12VAC 30-50-490



Case Manager (CM) Qualifications• Employed by an

organization

• Self-employed

• Supervisor to Case Manager

• CM provider cannot supervise another CM provider

• Personnel Record

• Eight Hours of Training



Case Manager (CM) Qualifications• Parents, Spouses or

any person living with the individual

• CM cannot provide services to own child

• CM may provide service facilitation(SF) 12VAC 30-50-490



Case Management while on Wait list

• Individual’s who have Medicaid

• Documented in plan of care

• Case Management Activities 12 VAC 30.50.490)



The Team Approach to the Plan of Care Meeting

Participant, Family, and Providers



What does the Team approach ensure?• Satisfaction with services

• Health and safety

• Coordination

• Organized

• Unduplicated

• No breaks in service

• Optimal service delivery(DD Waiver Manual, Chapter IV)


Department of Medical Assistance ServicesWho does the case manager contact for a Plan of Care Meeting?• Participant and/or his/her

family,

• All current service providers and

• Friend, Legal Guardian, significant other

• Date/Time/Meeting location/advance notice

(DD Waiver Manual, Chapter IV)



What is the goal of the Plan of Care Meeting? • Person Centered

• Decision-Making

• Discuss concerns

• Satisfaction with Services/Meeting needs




What is the goal of the Plan of Care Meeting?

• Short and Long-term goals

• Focus of meeting

• Target date

• Effective and Consistent




Case Management• What is Case Management?

– Case Management activities include:• Assessing and planning• Linking• Coordinating• Monitoring/Follow up • Making Collateral Contacts• Advocating• Education and Counseling• Enhancing community integration (12 VAC

30.50.490)



What are other important topics?

• Freedom of Choice• Future planning:

– Aging– Graduation/Transition

Planning– Aging Caregiver– Behavioral/Crisis

Planning• Contingency plans



Choice of ServicesWhy is choice important? • Empowering• In control of their lives • Helps CM to develop the POC Who makes the choice?• Is the participant over 18?• Does he/she have the ability to make their

own choices?• Does he/she direct his own care?• Does he/she have a legal guardian?



Resources to help with Choices

• Network with other Case Managers• DMAS website• Develop your own provider list for your

families



Trends Trends Seen By DD Waiver Analyst



Trends Seen By Analysts• Level of

Functioning Assessments

• DMAS 456• Social Assessment

• DMAS 457• DMAS 97 A/B• DMAS 99• Environmental

Modifications



Trends Seen by Analysts• Assistive

Technology• Consumer Directed

and Agency Directed Companion

• In-Home Residential

• Therapeutic Consultation

• Denial of Services



How to reduce Trends The key to successful plan submissions is

error free work Double check that no spaces are left blank

and that the documentation matches the requested hours of service

Complete justification is required for requests for services including adding new services, increases or decreases in services and/or service hours



How to reduce TrendsUse the DD Waiver Fax Sheet • Please use the fax cover sheet

– Identify the type of plan and include any special instructions you may have for DMAS

• Resubmissions/Pend responses– Identify on the new fax sheet what your

resubmission is addressing – Note when submitting a response to a pend you do

not need to resubmit the entire packet. You only need to submit the information that is being requested on the Case Manager Status Report



Face to Face Visits



Face to Face Meetings• A face to face (FF) visit is defined as …

the case manager or service provider must meet with the individual in person and that the individual should be engaged in the visit to the maximum extent possible. (12VAC30-120-700)

– A face to face contact is required at a minimum

of every 90 days. (Chapter IV, 12 VAC 30-50-490)



Face to Face Meetings• Documentation

Requirements:

– FF with individual – Assessment of service

satisfaction – Any unmet needs– Individual’s status – Service modification




TIPS for FF• Case notes may be in the form of contact-

by-contact entries or a monthly summary as long as they correspond with a contact log. These notes must include the date, type, and reason for each contact. – All entries must be signed (first initial and last

name minimum) and dated.– Face to face visit notes are not quarterly

reports and need to be documented separately.



Case Management Review process



Case Management ReviewAt a minimum, every three months review:

Plan of care equals a FF with the individualQuarterly goals and objectives to ensure

they are being met, andAny necessary modifications to the plan of

care



Case Management Review• At least once per plan

of care year this review must occur in the individual’s home environment.

(12VAC30-120-720.E.b.1-3c.)



Why is this process separate from the face to face contact meetings?

• Comprehensive evaluation must include the following:

• The DMAS 457 support documentation which includes all of the individuals goals and objectives as agreed upon in the team meeting.

• The plan of care which includes all DD waiver services including case management.

• The service providers quarterly reports submitted to the case manager. (12VAC30.120.720.E.1.b)



These are the required components for your Quarterly ReportRevisions to the Plan

Of Care General status

Significant eventsProgress or lack of

progress in goalsSatisfaction with

Services and Case Management (DD Waiver Manual, Chapter IV)



Quarterly Review• All service providers must complete a

written semiannual report and forward to the case manager.



Quarterly Review• Exception! When any sporadic and

temporary services such as Respite, Assistive Technology, Environmental Modification, PERS and Crisis Stabilization are provided during the quarter, the case manager must obtain details of the services from those providers and include this information in the Quarterly report. (DD Waiver manual, Chapter IV)



Goal and Objective Review • The Quarterly Review schedule is based on the start

date of the POC.

• Initial plan year view

POC Start Date Quarterly Due Semi Annual Due

Quarterly Due Jan 1, 201 April 1, 2012 July 1, 2012 October 1, 2012

Months 1 2 3 4 5 6 7 8 9 10 11 12



Goal and Objective Review • Quarterly Reviews are planned around the POC

start date.

• Renewal Plan Year View

Annual Plan Due Quarterly Review Semiannual Due Quarterly Due

January 1, 2012 April 1, 2012 July 1, 2012 October 1,2012

Months 13 14 15 16 17 18 19 20 21 22 23 24



Emergency Plans of Care (POC)



Processing Plans of Care (POC)• Emergency plans

What is considered an emergency?• It is at the discretion of DMAS staff

whether a plan falls into the emergency criteria for a plan to be worked out of the normal work flow

• When a Case Manager requests emergency consideration, a team review will take place prior to the deciding to work the plan



Emergency (POC)

• Most emergency plans are medical in nature

• Poor planning on your part does not constitute an emergency



Emergency (POC)

• Examples of emergency plans:– A participant has broken her hip and needs

additional hours of service

– A participant is experiencing skin breakdown and needs additional hours

– How do you define an emergency?



Processing Emergency (POC)

Crisis vs. Emergency

• Crisis is defined as a mental health emergency

• DMAS is required to review crisis plans as they are received so authorization can be obtained within 72 hours



Interruptions and Extensions



The difference between Extension Letters and Interruptions

• Extensions are requested prior to beginning services

• Interruptions are requested after the participant has started service and has not received services in thirty days



When is an Extension letter needed?

– When a participant is unable to initiate services within 60 calendar days of becoming Medicaid eligible and enrolled an extension letter is required (DD Waiver Manual, Chapter IV)



What are the extension letter requirements?

• Requests must be in writing• Letters must be received by DMAS within the 30 day

period the extension is requested • No more than 4 extensions may be approved• Extension letters must contain the specific start and

end dates for the requested time period • Extension letters must contain information why more

time is needed to initiate waiver services (12VAC30-120-720.9.)



When are plan interruptions needed?

• When a participant has not received DD Waiver services for more than 30 days

• It is the Case Manager’s responsibility to submit an Interruption POC to DMAS



How do you interrupt a POC?• If possible, the Case Manager should meet

with the participant and/or family member to obtain their signature on the Plan of Care

• (Note: participants should be notified that services can only be interrupted for 90 days and then the withdrawal process will begin)



How do you interrupt a POC?• At the top of the Plan of Care, the Case

Manager should check the box for “Interruption” and update the DMAS 457 to explain why services are being interrupted then submit the documents to DMAS



How do you restart a POC?• Meet with the participant and/or family and

providers to discuss the POC • Resubmit the updated POC marked

“Revision” with an updated 457 • The supporting documentation for the

services being requested– Note: DMAS has the same work time for

restarting a POC as regular plans that are submitted daily. (DD waiver manual, Chapter 4)



Transferring Case Management Services



Transfer of Case Management

• If a participant wishes to “switch” to another case manager, the current CM is responsible for:– Send a Case Management list– Informing the participant that the Case

Manager needs written permission to exchange information (a copy of your agency’s Consent Form) with the new case manager they have selected



Transfer of Case Manager–When a participant has selected

another case manager and provided consent to exchange information,

–The existing case manager copies the complete record and forwards it to new case manager



Transfer of Case Manager–Current case manager needs to

follow-up with a phone call and document that they updated the new case manager on the case

–The case manager must inform DMAS and individual in writing of the change (fax is fine) and submit a copy of the consent form to DMAS



Housekeeping Tips



Housekeeping Tips• Verify that all

paperwork submitted by providers is correct prior to submitting it to DMAS

Ensure that plans and supporting documentation are submitted to DMAS in a timely manner Submit renewal plans

no earlier than 60 days prior to plan start date



Housekeeping • Required

Documentation– POC can only be

worked with submission of complete documentation. Please refer to your Provider Manual for required documentation, service limits, and exclusions.



Housekeeping • Participants should be notified that

services can only be interrupted for 90 days and then the withdrawal process will begin.

DMAS has the same work time for restarting a POC as regular plans that are submitted daily.



Housekeeping Tips Case Management and Service Facilitation

documentation should be separate

Legible writing

Objective written documentation notes as to why there are no other providers available to provide care this includes advertisements and number of attempts.

Document, Document, Document



–Abuse, Neglect and Exploitation



We Need Your Help!• Children's Stats• In FY 2011 CPS

received• 49,619 reported

cases of abuse or neglect

• 6,116 were founded cases

• 30% under the age of 4

• Virginia APSreceived over 17, 936 reports of adult abuse, neglect and/or exploitation.

• 59% of the reports were substantiated



For this purpose . . .• Adults are:

– Persons 18 years old or older who are incapacitated

– Persons age 60 and older

• Children Are:

• - Persons under the age of 18 years



Types of Abuse• Adults

– Physical– Verbal– Emotional– Sexual– Neglect– Self Neglect– Exploitation

• Children– Physical– Sexual– Neglect– Home Alone– Emotional– Medical

Financial Exploitation is a growing trend in Abuse



What is a Mandated Reporter?• A mandated reporter is an individual who

is required by Virginia law to report situations immediately in which they suspect anyone that

may have been abused, neglected or exploited,or is at risk of being abused, neglected or exploited



Who must report?• Medical professionals § 54.1-2503 of the Code of Virginia,

– Persons licensed to practice medicine or any healing arts– Hospital residents, interns, and nurses– Any emergency medical services personnel certified

by the Board of Health § 32.1-111.5• Social workers and Probation officers

– 54.1-2400.1• Teachers and school personnel

– Public, private, kindergarten or nursery school• Child care providers



Who must report?• Accredited Christian Science practitioners• Mental health professionals• Law enforcement officers• Professional staff• Mediators certified to receive court

referrals• Designated court appointed special

advocates



Employers of Mandated Reporters:• Must notify mandated reporters of their

obligation to report• May establish in-house procedures for

reporting• Cannot prohibit employees from reporting

directly to APS



WHEN do I report?• Report situations they

encounter while performing their official job duties

• The report must be made immediately upon becoming aware of the situation of abuse, neglect and/or exploitation



Making a Report• When to report

– Immediately• How to report

– Call local department of social services– Or call Hotline 24 hrs a day, 7 days a week

• WHAT do I report? – The identity, age, and location of the alleged abused

individual– Any information about the suspected abuse, neglect or

exploitation

For Children1-800-552-7096

For Adults1 (888) 832-3858)



Questions for APS DSS Specialists

If you have questions about reporting suspected adult abuse, neglect and/or exploitation, or other questions regarding your status as a mandated reporter, call an APS DSS Regional Specialist:

Eastern Region (757) 491-3983Central Region (804) 662-9783Western Region (276) 676-5636Piedmont Region (540) 204-9640Northern Region (540) 347-6313



You are Key!Report suspected Abuse, Neglect and

Exploitation!You can help vulnerable

children and adults suffering in silence have safer, happier

and more productive lives!



Questions and AnswersFor questions, please contact the Division of

Long-Term Care at 804-225-4222, press option #1 or by fax at 804-612-0050.

Please visit the DMAS website at:www.dmas.virginia.gov

Thank You!!!!!!

http://www.dmas.virginia.gov/



Look Ahead • “TO INFINITY AND BEYOND”



What to Expect During a Quality Management Review(QMR)




What Generates a Review?• Statewide Sample

– A computer generated list is created and reviews are scheduled randomly.

• Complaints– DMAS receives a concern regarding services

from a constituent.



Quality Management Review • Unannounced• May be on-site or desk review • May include

• observation of service delivery, • face to face or telephone interviews

with the consumer and caregivers.

• Usually 2 – 5 days in length



QMR (cont’d)

Upon arrival, Analyst will:

• Request charts be gathered together in a central location.

• Secure a workplace to conduct the review.



QMR (con’t)

• Electronic Records– Analyst should have access to electronic

records– Analyst may request that some portions be

printed– No personal information from the analyst will

be supplied in order to gain access to the electronic record.



QMR (cont’d)

During the review:• Analyst may ask questions regarding

your documentation.• Analyst may request additional

documentation.• Analyst will let you know how long

the review will last and time of the Exit Conference.



Quality Management Review (cont’d)• Exit Conference will usually occur on the

last day of the review and may be via telephone or alternate media.

• You may have any of your staff attend.



Items to be Reviewed

• Assessments• Plan Of Care (CSP)• Supporting Documentation (457)• Quarterly/Semiannual Reports (of other

providers)• CM documents and documentation



Items to be Reviewed (cont.)

• Individual records –Appropriate data, contact notes, or progress notes–Reports–Documentation



Items to be Reviewed (cont.)

• Personnel records (qualifications, background check, references)

• Policies and Procedures (At a Minimum)

– Hiring– Development of Service Plans – Admissions and Intake– Reporting of APS and CPS cases– Record Retention



QMR Findings Letter Contents• Summary

• Technical Assistance – Issues not in compliance with Medicaid

policy that should be addressed by the provider.

• Corrective Action Plan (CAP) – Situations in which the provider has failed to

comply with federal and state regulations or policy guidelines and procedural changes are required.



Recent Findings Trends

• Documentation demonstrates consumers

are receiving any necessary medical care.

• Documentation of side effects of medication and all health, safety and welfare incidents or concerns.



Recent Findings Trends (cont’d)

• Documentation of progress towards CSP goals and or changes.

• Annual documentation includes summary of each quarter, satisfaction with each service and justification for continuation or discontinuance of services/waiver.



Recent Findings Trends cont’d

• Quarterly review of status of each service participant is receiving or service authorized on CSP.

• Quarterly review accurately reflects the individual’s responses to services for the quarter.

• Quarterly review documents participants choices and involvement with development of plan.




• The Case Manager’s quarterly review includes a summary of each providers quarterly or semi-annual review.

• The Case Manager’s quarterly review is completed within the required timeframe.

• CM job responsibilities are completed regardless of billing status.




• Face–to–Face contact occurs at least every 90 days.

• Documentation of Face–to-Face contact include components required per manual and VAC regulations.

• All CM and SF documentation maintained separately.




• Billable and legible monthly CM contact notes.

• Contact notes signed and dated.• Participant’s full name or Medicaid

number on each page. • Health and safety needs documented in

plan and reflected in services.



Any Questions?

Case Management Training

Documents