TSWF Case Management Pediatric AIM Form Training January 2019 Jan-Apr 2019 Form Version

Recent Changes The following group of slides reflect changes made to the form.

Case Management and Case Management Peds Updates Added radio buttons to specify patient is/is not candidate for CM. Return to Table of contents

Case Management and Case Management Peds Updates Moved Obsolete Terms to Demographics tab. Removed duplicate ‘Patient is a candidate for CM’ and added it to Obsolete terms. Return to Table of contents

Why Use TSWF CM Pediatric 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 Easy access to references for clinical decision-making Improved continuity of care and healthcare outcomes CM Reference links  Presenter Notes:

Why Use TSWF CM Pediatric AIM Form? 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  Presenter Notes:

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

Resources Form version, links to MilSuite, TSWF Navigator, TSWF Resources, and Change Log are listed at the top

Demographics Tab Specify whether or not patient is a candidate Presenter notes:

Demographics Tab Screening for CM Screening patients Presenter notes: Select EFMP only if patient is enrolled – does not apply if other family members are EFMP but patient is not. Include dx, date of program reevaluation.

Demographics Tab (cont.) To type text in an empty field, place cursor near colon/prepositioned text and begin typing Presenter notes:

Military History Tab Documentation to reflect AD member history: Since this is the child’s record, emphasize that this describes the parent(s) and how child may be impacted during deployments/TDYs.

General Assessment Tab Emphasizes a full system review: Enhanced care planning and needs identification Presenter notes: Comprehensive system review includes Dental

General Assessment Tab (cont.) Additional documentation to assess needs specific to: Dietary Behavioral Health Episodic care mgmt (Continuity of Care Issue should be investigated)

General Assessment Tab Medical Conditions Comprehensive review by body system: Allows for individualized need identification

General Assessment Tab Behavioral Health Conditions Presenter Notes:

General Assessment Tab Additional Medication Documentation Full review of medication: Evaluate understanding and reason for prescribed meds

Functional Assessment Tab Specify ADL capabilities ‘Requiring Assistance’ box: CMs documentation required in the event the child is dependent

Functional Assessment Tab (cont.) Assess Living arrangements: Ensure ongoing medical care support is available in the event the primary home of record changes, to ensure continuity of care is uninterrupted. For Example: Coordination of complex care needs would vary in the event a family is divorced and the child’s home of record changes In the course of a deployment the child is moved to a family member in another state and/or region

Functional Assessment Tab DME 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 DME (cont.)

Psych/Soc Assessment Tab Psych/Social Tab: Opportunity to assess additional family or Behavioral Health support, if needed

Psych/Soc Assessment Tab (cont.) If patient is a student, document this as occupation, grade, type of schooling; daycare, homeschool, public, private, etc.

Psych/Soc Assessment Tab Environmental Concerns Comprehensive Environmental assessment should be completed and routinely reassessed to identify potential ‘triggers’ that could exacerbate existing conditions.

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

Health Habits/Wellness/Misc Tab Alcohol Enter AUDIT-C date and score here Beneficiaries who consume alcohol should complete an Audit C. The CM should coordinate results back to PCMH Team.

Health Habits/Wellness/Misc Tab 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 Comprehensive evaluation of specialized services is available. Utilize the “Other” section to identify additional services, if needed. Presenter notes:

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)

Content Management Sub-Working Group CHAIR - Maj Matthew J Royall ARMY - Dr. Robert Marshall NAVY - CDR Anja Dabelic AIR FORCE - Lt Col Thomas Mahoney DHA – CPT John Hudson-Odoi TSWF Feedback https://www.milsuite.mil/book/groups/tswf TSWF Website http://www.tswf-mhs.com/