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

2. 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:

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

4. 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

5. 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

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

7. Military History Tab

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

9. 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

10. 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

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

12. General Assessment Tab Behavioral Health Conditions

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

14. 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.

15. 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

16. Functional Assessment Tab Durable Medical Equipment (cont.)

17. Psych/Soc Assessment Tab

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

19. 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

20. Care Team Tab
Presenter notes:

21. 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.

22. CM Care Plan Tab

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

24. Definitions Tab
Presenter notes:

25. TSWF Resource Material
The TSWF repository for training/educational materials and updates:

26. Comments or Feedback Contact
Form feedback / discussion forums:
TSWF resources / educational materials:
Local Clinical Systems Trainer (CST)

27. TSWF Service Leads ARMY – Dr. Rolando Merino NAVY – CDR Anja Dabelic
AIR FORCE – Maj Matthew Barnes & Maj Thomas Mahoney
TSWF Feedback

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