Case Management in North Carolina Additional Trainers Slides Mary Thornton & Associates, Inc Copyright

Brief Background Case management considered high risk by OIG and CMS Costs high, value uncertain Mostly abuse by states Resulted in a change to the definition of case management by Congress in the Deficit Reduction Act

Brief Background Definition change resulted in Interim Final Rule being issued by Bush administration Rule was put on moratorium under Bush because of outcry. CMS issues guidance for what remains. Rule rescinded under Obama – no new rule reissued.

Brief Background The federal government defined CM TCM is a form of CM – Same definition of services – Can restrict services to certain populations or geographic areas – Can restrict in behavioral health and in ID/DD to certain providers – CABHA in NC – Same rules on freedom of choice, not restricting access to other services, etc. See SPA model

Brief Background Remaining advice is a State Medicaid Director’s letter, the DRA definition, and the post-moratorium CMS –all in your handouts North Carolina submits SPA for TCM – rescinds individual community support. – This is not a one for one change in the continuum of care –these are very different services

Case Management Development of Service Models

Case Management Team Model should be one that allows for independence not a recruiter for other services you provide Team of case managers that report to a separate supervisor prevents capacity from being stuck in places it cannot be used – Can therefore be centrally located

Case Management Much work can be done by phone – If consumers have phones – regular contact, reminders, etc. – Coordination of care – huge issue – much more efficient by phone – Allows for more direct work with Individual Emphasis on phone work Allows for higher caseloads which will be important

Case Management Team Receives referrals – Need a diagnosis and determination that these services are necessary – Referring professionals should have clear guidelines for eligibility requirements and level of need Should not be referred solely for transportation Other ad hoc interventions are not appropriate – There should be the capacity to deal with emergency issues –agency policies need to be developed

Case Management Team Types of CM – Strict brokerage: less need for extensive outreach, linkage and advocacy needed. May have other internal, external resources – Intensive models: more community based work – focus on advocacy and outreach – problem-solving and recovery strategies – Clinical: therapeutic relationship with some case management

Case Management Team Internal referrals – Should be formal systems for each type of service – Consumer offered choice – Documentation of choices offered

Communication Danger is that silo’d care will result – Communication strategies need to be developed and staff held accountable – Case manager plays very central role in this – Can you use technology? Electronic medical record Other forms

Case Management CASE RATES

Case Rates Built on an assumption of cost, caseloads, and average services Often proof of service requires minimum interactions Note always that the minimum is the absolute floor See CMS Toolkit for States to Develop their State Plan Amendments

Case Rates With case rates and fee for service both: Required services must meet Medicaid requirements: – Each and every service documented –you have the option of a daily note, but this must still list specific services provided – should not be a general summary – Services and service definition critical – Medical necessity critical

Case Rates Compliance risks: – Everyone gets the floor regardless of need – Clients kept in services by just providing additional services regardless if medically necessary – Front loaded or back loaded services –all face to face in last week of month every month – Cookie cutter treatment plans

North Carolina Payment Weekly case rate with: – Minimum 15 minute weekly intervention – not necessarily face to face – Minimum monthly face to face Authorized at the time of the first day of the service – Short term service: 90 days original auth; 60 day reauthorization Ordered by MD, NP, PA, Phd – note scope of practice limitations

Program Development TCM

CM Program Assignment of staff – based on estimated caseloads (up to 50 but based on acuity) Reporting relationships – trying to maintain independence Strategic Plan for implementation

How do I move forward? Plan for development of program – Development of business plan Average caseloads: should not assume everyone can handle month pro forma – Job descriptions: SAI; power, etc. – will determine training needs – Consumer and family training – start early Standardized – this should not have to be individually negotiated between each case manager and family/consumer – CM training – Assignment of cases – geographic if possible – Development of communication strategy