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

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

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

4. 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

5. 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:

6. 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:

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

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

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

10. 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.

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

12. 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.

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

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

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

16. General Assessment Tab Behavioral Health Conditions
Presenter Notes:

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

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

19. 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

20. 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

21. Functional Assessment Tab DME (cont.)

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

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

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

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

26. 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.

27. 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

28. Care Team Tab
Presenter notes:

29. 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:

30. CM Care Plan Tab

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

32. Definitions Tab
Presenter notes:

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

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

35. 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 TSWF Website