Assuring your TCM program is in compliance TCM Documentation Training November 1, 2012 Assuring your TCM program is in compliance Presented by Patricia Calloway and Pat Ericsson TCM Conference April 2017

Topic for discussion Case Manager qualifications Agency qualifications Program policies Audit file Best practices

Agency Qualifications Must have system of coordination between programs Demonstrate experience in providing case management Employ staff with CM qualifications Have or establish referral systems for linkages

Agency Qualifications – Cont’d 5 year minimum of providing CM to target group Admin capacity to ensure quality of services Financial management capacity to comply with OMB A-87 Capacity to document and maintain case records to meet regulation standards Ability to evaluate quality and effectiveness

Case Manager Qualifications RN or PHN with active license Bachelor’s degree with agency approved CM training Documentation of initial and annual time survey training Duty statements NPI Documentation of case management training for Non – RN/PHNs

Program Policies Part of the Annual Participation Prerequisite: Performance Monitoring Plan/Non- duplication/Care Coordination Freedom of Choice Fee Mechanism Managed Care MOU

Program Policies - continued Annual Participation Prerequisite subcontractors Provider Participation Agreement Signature Authority MEDS Access Sub program codes Third Party Liability

Program Policies - continued TCM Payment System Time Surveys Confidentiality Duty Statements Payment by invoice Quality Assurance Chart audit and peer review

Audit File Billable vs Non-billable Encounter Logs Organizational Charts Duty Statements/Job Description Case Management Qualifications Billable vs Non-billable Encounter Logs

Best Practices Best Practices Required Documentation Red Flags Duty Statements Client satisfaction Grievance procedure Required Documentation Red Flags Resources

Alameda County Public Health Nursing : Patient Experience “Staff is very friendly and the nurse answered all my questions” “She was great, very helpful. She is the right resource, and was helped right away!” “Excellent! I like her, she was right! I’d recommend xxxx. She is very helpful and I love her to death!” “She is excellent! Best nurse around! So understanding!” “Professional, super nice, really sweet” “Every staff RN PHN service was sufficient” “I am going to move out of state, and the nurses gave me really good references!” “This helps lots of people” “Helpful to me, took her time and explained everything. She was very good” “Definitely recommend, I really enjoy working with xxx” “She really helped me. Very nice” “She was very helpful and she was really nice” “Very nice, very helpful . I am very happy” “I had 2 strokes. I needed a new pharmacy and delayed meds because medical needs to do that in the clinic” “Everything was good, very satisfied” “Always helpful to provide more information. Xxx was very nice” “Was very helpful, they helped me a lot” “Yes, very helpful. I got to know a lot of things” “It’s great service. Provided good information and literature” “They are my best friends” “Good worker, helped me a lot. Kept me from stressing out” “Timing of visits can be off; otherwise happy with services” “She was on top of everything” “xxx. She is nice, helpful – Tell her I said ‘hello’” “She really helps me. I want her to come back” “xxx goes above and beyond. I can’t say enough good things about her” “It’s been great!”

Freedom of Choice Must have a Freedom of Choice policy Best Practice: Note on assessment form that Freedom of Choice was explained

Freedom of Choice Client must be told: Services are voluntary May go to a different TCM provider May request a different CM May terminate TCM services at any time

Fee Determination and Waiver It must be documented that the client was reviewed for a fee for TCM services Each LGA or TCM provider must have an income-based scale to determine if client must pay a fee There are no state or federal parameters

Fee Determination and Waiver If it is determined that the client must pay a fee, the fee may be waived by the Case Manager Client has a communicable disease CM determines client will not continue in the Program and could be detrimental to the client

Billable vs. Non-Billable TCM Documentation Training November 1, 2012 Billable vs. Non-Billable A billable encounter is: Face-to-face visit with Medi-Cal client In TCM target group During which case manager renders one or more TCM service components. All TCM criteria must be met to be billable

Performance Monitoring Plan LGA must submit their Performance Monitoring Plan with their Annual Participation Prerequisite. Details how LGA will ensure case management service will not be duplicated Details your Quality Assurance Plan

Quality Assurance No formal requirements exist – each LGA should determine its own QA protocols LGAs develop a written policy for reviewing TCM cases

TCM Documentation Training November 1, 2012 Quality Assurance Best Practices Include criteria, sample methodology, and frequency of reviews May involve coordinator’s review, supervisor review and/or peer review Include periodic checks to assure that client case documentation, encounter logs, and billings are consistent in details

Common Documentation Errors Not clearly identifying the TCM service that was provided Not identifying one of the four TCM service components Billing for a TCM encounter when a TCM service has not been documented

Common Documentation Errors Not addressing who, what, when, where and why Not clearly distinguishing individual care plans, assessments and progress notes within family charts Not clearly identifying how a client meets the Target Population criteria

Red Flags for Auditors Not using TCM words in case file documentation Making frequent client visits without documenting client outcomes or new needs Documenting multiple home visits where no new information was received or new referrals made

Red Flags for Auditors Needs identified on the Assessment are not the same needs identified in the Care Plan Using local agency acronyms without a key to full names or meanings Illegible writing Documenting for a family versus an individual

Resources State Website LGA Website TCM FAQs MAA/TCM Regional Meetings TCM Guidelines Workgroup Annual Conference

TCM Documentation Training November 1, 2012 Resources-FAQs View the complete FAQ document: https://sites.google.com/site/calgacons ortiumworkgroups/home/tcm- workgroup/tcm-faqs

TCM FAQs

TCM FAQs

Questions