1. T ARGETED C ASE M ANAGEMENT AND E NCOUNTERS P ROGRAM I MPLEMENTATION 2016 LGA C ONSORTIUM A NNUAL C ONFERENCE B EVERLY S. R ANDOLPH – S AN D IEGO C OUNTY S UE G UEST – C ONTRA C OSTA C OUNTY

2. A RE Y OU R EADY ?  Fee Mechanism  Encounter Log  Documentation  Annual Participation Prerequisite (APP)  Provider Participation Agreement (PPA)  Policies  National Provider Identification (NPI) Number For Agency and For Case Managers  Engagement Policy/Referral Response  Managed Care MOU 2 2016 LGA Consortium Conference - Targeted Case Management and Encounters Program Implementation

3. F IRST V ISIT  Determine Target Population  Assess for Duplication of Services  Administer the Fee Mechanism  Freedom of Choice/Voluntary Services  Confidentiality/ HIPAA/Release of Information  Introductions of Program  Contact Information  Comprehensive Assessment 3Targeted Case Management and Encounters Program Implementation

4. TCM F LOW : A SSESS THE C LIENT TCM Eligibility Care Plan Referrals Client Progress Reassess and Revise 4Targeted Case Management and Encounters Program Implementation

5. T HE F OUR TCM S ERVICE C OMPONENTS  Assessment/Periodic Assessment  Care Plan Development/Periodic Reassessment  Referral Activities  Monitoring and Follow-up 5Targeted Case Management and Encounters Program Implementation

6. W HAT ’ S R EQUIRED FOR A SSESSMENTS  The client’s needs/problems are documented:  In conjunction with the client  Must be comprehensive  May take more than one visit 6Targeted Case Management and Encounters Program Implementation

7. C OMPREHENSIVE A SSESSMENT  Medical/Mental  Community Living/Life Skills  Vocational/Educational  Physical  Social/Emotional  Family Social Support  Housing/Physical  Legal 7Targeted Case Management and Encounters Program Implementation

8. C OMPREHENSIVE A SSESSMENT  If the Assessment occurs over multiple visits, then document:  Specific aspects addressed in each encounter  Why the Assessment could not be completed in one encounter  Why multiple face-to-face encounters are required to complete the Assessment 8Targeted Case Management and Encounters Program Implementation

9. C OMPREHENSIVE A SSESSMENT  If the client has no needs in an area of the Assessment a separate note is not necessary.  Sufficient documentation is a statement or checkbox stating: “No needs identified ” 9Targeted Case Management and Encounters Program Implementation

10. TCM F LOW : D EVELOP A C ARE P LAN TCM Eligibility Comprehensive Assessment Referrals Monitor Reassess and Revise 10Targeted Case Management and Encounters Program Implementation

11. C ARE P LAN  Must be developed with the client  Goals and referrals must be linked to needs identified in the Assessment  Must be signed by:  Case Manager  Supervisor 11Targeted Case Management and Encounters Program Implementation

12. C ARE P LAN  Must include frequency and duration  May be completed during the Assessment encounter  Bill for either Assessment or Care Plan Development 12Targeted Case Management and Encounters Program Implementation

13. F REQUENCY AND D URATION  Frequency  How often the Case Manager needs to visit the client  Duration  How long the Case Manager needs to visit the client  “As needed” is not sufficient 13Targeted Case Management and Encounters Program Implementation

14. TCM F LOW : M AKE R EFERRALS TCM Eligibility Comprehensive Assessment Care PlanMonitor Reassess and Revise 14Targeted Case Management and Encounters Program Implementation

15. R EFERRAL A CTIVITIES  Referrals must be linked to needs in the Care Plan  No referrals are too minor, as long as they relate to the health and well-being of the client 15Targeted Case Management and Encounters Program Implementation

16. R EFERRAL A CTIVITIES  Types of Referrals  Case Manager refers a client to a service and makes an appointment  Case Manager encourages client to use a resource 16Targeted Case Management and Encounters Program Implementation

17. R EFERRAL A CTIVITIES  Multiple Referrals  If a client does not utilize a referral, Case Manager may offer more referrals  Document: Why additional referrals are needed How the Case Manager is addressing barriers 17Targeted Case Management and Encounters Program Implementation

18. R EFERRAL A CTIVITIES  Family Referrals: Referrals that meet the needs of multiple family members may only be billed to one TCM client 18Targeted Case Management and Encounters Program Implementation

19. TCM F LOW : M ONITOR P ROGRESS TCM Eligibility Comprehensive Assessment Care Plan Referrals Reassess and Revise 19Targeted Case Management and Encounters Program Implementation

20. M ONITORING AND F OLLOW -U P  All referrals with an appointment date must be followed up within 30 days  Follow-up may be:  Face-to-Face  Phone  Text  Mail  The initial referral encounter may be disallowed if follow-up is not performed within the 30 days 20Targeted Case Management and Encounters Program Implementation

21. M ONITORING AND F OLLOW -U P All referrals receive a follow-up! 21Targeted Case Management and Encounters Program Implementation

22. M ONITORING AND F OLLOW -U P D OCUMENTATION  Did the client utilize the referral or attend the appointment?  What was the outcome of the appointment?  Did the referral meet the client’s needs? If not why?  What are the next steps or further actions needed to meet the client’s needs? 22Targeted Case Management and Encounters Program Implementation

23. TCM Flow: Reassess and Revise TCM Eligibility Comprehensive Assessment Care Plan Referral s Monitor 23Targeted Case Management and Encounters Program Implementation

24. P ERIODIC R EASSESSMENT  When the client’s circumstance has changed such as:  Eviction  Birth of Baby  Domestic Violence  Hospitalization 24Targeted Case Management and Encounters Program Implementation

25. P ERIODIC R EASSESSMENT  Update the existing Care Plan  New Need  New Referral 25Targeted Case Management and Encounters Program Implementation

26. P ERIODIC R EASSESSMENT AND C ARE P LAN R EVIEW  Shall be conducted at least every six months  Modify the care plan to address new needs and/or conditions  Must be signed by Case Manager and Supervisor 26Targeted Case Management and Encounters Program Implementation

27. C ARE P LAN R EVIEW  Entire Care Plan should be reviewed with the client to determine:  What needs and goals have been met or not met  Whether services should be continued, modified, or ended  A new Care Plan is not necessary if new needs are not identified  27Targeted Case Management and Encounters Program Implementation

28. TCM: Case Management & Encounters Program Implementation 28Targeted Case Management and Encounters Program Implementation

29. TCM: Case Management & Encounters Program Implementation For More Information or Answers 1) Monthly Conference call Meetings with the “TCM Guidelines Workgroup” 2) The TCM FAQs Website 3) Your LGA Coordinator 29Targeted Case Management and Encounters Program Implementation

30. TCM: Case Management & Encounters Program Implementation 30Targeted Case Management and Encounters Program Implementation