Adult Case Management (CM) TSWF AIM Form Training APR2018 JAN-APR Form Version

Why Use a TSWF AIM Form? Provides comprehensive identification of patient care needs (historical and current) to primary and interdisciplinary care teams Supports dedicated care management requirements through: Standardized and improved evidence based documentation Detection of care coordination requirements Reduced variance and fragmentation of care management activities Provides easily accessible references for clinical decision-making Improves continuity of care and healthcare outcomes Provides reference links for CM easy access Critical Tool in Complex CM Core Position Requirements: Address total needs of patient and family on a regular and recurring basis Improve collaboration with interdisciplinary teams to improve outcomes ‘Proactive management’ to support and address comprehensive health needs and transition of care requirements, minimize fragmentation, and promote patient safety, quality of care, and cost- effective outcomes Supports improved capability for MHS CM tracking and reporting  Presenter Notes:

Demonstration of Form The following slides will walk through each tab of the Case Management Adult AIM form.

Resources At the top of this tab you will find the form version as well as links to MilSuite, TSWF Navigator, TSWF Resources and Change Log. Presenter notes: MilSuite, TSWF Navigator, TSWF Resources and Change Log is at the top of every tab

Demographics Tab Enhanced data tracking and MHS reporting capability ‘NEW’ Dedicated Case Management Adult TSWF Form Standardize and synchronize Complex Case Management through comprehensive assessments, improved interdisciplinary team communication, continuity of care with warm hand-off, and improved outcomes Enhanced data tracking and MHS reporting capability Visit Type has expanded options Document if accepting or declining services Triggers to identify and document need for enhanced benefit considerations EFMP / ECHO Presenter notes: Consult Service and local MTF policy

Demographics Tab Specialty Case Management Follow Service policy concerning copy and paste guidance. Presenter notes:

Military History Tab

General Assessment Tab Emphasizes a full System review: Enhanced care planning and needs identification Presenter notes: Blues Clues DoD/VA CPG

General Assessment Tab (cont.) Continuity of care issues should be investigated Ensure coordination with PCM and interdisciplinary team to support warm hand off Additional documentation to assess needs specific to: Dental Dietary Behavioral Health Episodic care management

General Assessment Tab Additional Medication Documentation Full review of medication: Coordinate with beneficiary to evaluate understanding and reason for prescribed meds Validate initial or refill of prescribed meds have been picked up by beneficiary and/or barriers identified that require CM engagement

General Assessment Tab Medical Conditions Comprehensive review by body system: Allows for individualized need identification Identified care needs should be addressed with PCM teams

General Assessment Tab Behavioral Health Conditions

Functional Assessment Tab Specify ADL capabilities “Requiring Assistance” box: CMs documentation required in the event the patient is dependent

Functional Assessment Tab Durable Medical Equipment Assess Living arrangements: Ensure ongoing medical care support is available in the event the primary home of record changes to ensure continuity care is uninterrupted.

Functional Assessment Tab Durable Medical Equipment (cont.) Durable Medical Equipment (DME) specific details and needs can be documented here. A comprehensive DME section is available and should be utilized to identify needs along with documentation that CM follow-up was completed to ensure the family received the DME and has no additional questions. Routine evaluation of DME needs should be conducted to ensure there are no changes or new requirements based on changes with individual complex case requirements

Functional Assessment Tab Durable Medical Equipment (cont.)

Psych/Soc Assessment Tab

Health Habits/Wellness/Misc Tab Health Habits Assessment: Assess patients needs Coordinate any gaps for immunizations with the PCMH team and document

Health Habits/Wellness/Misc Tab Alcohol/Tobacco Assess for alcohol or tobacco use. If identified, documentation should include: Coordination with the Primary Care Provider/Team Resources/Benefits available to eligible beneficiaries and follow-up

Care Team Tab Presenter notes:

Care Team Tab Special Services/Referrals Presenter notes: Comprehensive evaluation of specialized services is available. Utilize the “Other” section to identify additional Services, if needed. Previous page identifies consults/referrals; therefore, it is not necessary to document this information in both areas.

CM Care Plan Tab

CM Care Plan Tab Army Additional Documentation Required for Army WTU CM Documentation Information applies to Service Member

Definitions Tab Presenter notes:

TSWF Resource Material The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/

Comments or Feedback Contact Form feedback / discussion forums: https://www.milsuite.mil/book/groups/tswf TSWF resources / educational materials: www.tswf-mhs.com Local Clinical Systems Trainer (CST)

TSWF Service Leads ARMY – Dr. Rolando Merino NAVY – CDR Anja Dabelic AIR FORCE – Maj Matthew Barnes & Maj Thomas Mahoney TSWF Feedback https://www.milsuite.mil/book/groups/tswf

TSWF Case Management Adult AIM Form Training APR2018 JAN-APR Form Version