Accend Services, Inc.

Adult Mental Health-Targeted Case Management

Polices and Procedures, and Guidelines for Service Delivery andDocumentation

Created: 7/1/2012

Last Updated: 4/9/2017

Table of ContentsCase Manager Qualifications, Supervision & Training............................................................................... 2

Experienced Case Manager......................................................................................................... 2Ongoing Supervision.................................................................................................................. 2Case Manager Trainee................................................................................................................ 2Case Manager Associate............................................................................................................. 2

Caseload and Frequency of Contact...................................................................................................... 2Case Management Eligibility Screening, Admission and Discharge............................................................ 3

Responsive Case Management Services............................................................................................ 3Criteria for Eligibility...................................................................................................................... 4Required Assessment Elements in Case Management......................................................................... 5Essential Steps in Case Management Admissions............................................................................... 6Discharge Procedures..................................................................................................................... 7

Administrative Discharge............................................................................................................ 7Clinical Discharge...................................................................................................................... 7

Discharge Documentation............................................................................................................... 8Recipient or Referral Appeal of Eligibility or Discharge Decisions...................................................... 9

Client Grievances or Complaints........................................................................................................... 9Client Grievances or Complaints: Health Insurance Programs and Providers........................................10

Case Management Service Provision Standards.................................................................................... 10Cultural Awareness in Service Delivery........................................................................................... 11Core AMH-TCM Services Defined.................................................................................................... 12

Assessment............................................................................................................................ 12Planning..................................................................................................................................... 13Referral and Linkage.................................................................................................................... 13Monitoring and Coordination.......................................................................................................... 14

Internal Service Coordination and Monitoring.............................................................................. 14Case Management Services During Facility Placement.................................................................. 15

Recording Collateral Contacts........................................................................................................ 16Case Management Outcomes............................................................................................................. 16

Goals and Objectives for Case Management Services........................................................................ 17Goals..................................................................................................................................... 17Objectives.............................................................................................................................. 19

Objective Documentation.................................................................................................................. 22Addendum: Client Grievances or Complaints........................................................................................ 27

Medica....................................................................................................................................... 27Complaint and Appeal Procedure............................................................................................... 27

Blue Plus (Blue Cross Blue Shield of Minnesota)............................................................................... 28UCare......................................................................................................................................... 29UCare Provider Manual: Grievances................................................................................................ 30Minnesota Health Care Programs: Health Plan Appeals State Fair Hearings and Grievances....................33

Accend Services, Inc.

Adult Mental Health-Targeted Case Management

Polices and Procedures, and Guidelines for Service Delivery andDocumentation

Created: 7/1/2012

Last Updated: 4/9/2017

Table of ContentsCase Manager Qualifications, Supervision & Training............................................................................... 2

Experienced Case Manager......................................................................................................... 2Ongoing Supervision.................................................................................................................. 2Case Manager Trainee................................................................................................................ 2Case Manager Associate............................................................................................................. 2

Caseload and Frequency of Contact...................................................................................................... 2Case Management Eligibility Screening, Admission and Discharge............................................................ 3

Responsive Case Management Services............................................................................................ 3Criteria for Eligibility...................................................................................................................... 4Required Assessment Elements in Case Management......................................................................... 5Essential Steps in Case Management Admissions............................................................................... 6Discharge Procedures..................................................................................................................... 7

Administrative Discharge............................................................................................................ 7Clinical Discharge...................................................................................................................... 7

Discharge Documentation............................................................................................................... 8Recipient or Referral Appeal of Eligibility or Discharge Decisions...................................................... 9

Client Grievances or Complaints........................................................................................................... 9Client Grievances or Complaints: Health Insurance Programs and Providers........................................10

Case Management Service Provision Standards.................................................................................... 10Cultural Awareness in Service Delivery........................................................................................... 11Core AMH-TCM Services Defined.................................................................................................... 12

Assessment............................................................................................................................ 12Planning..................................................................................................................................... 13Referral and Linkage.................................................................................................................... 13Monitoring and Coordination.......................................................................................................... 14

Internal Service Coordination and Monitoring.............................................................................. 14Case Management Services During Facility Placement.................................................................. 15

Recording Collateral Contacts........................................................................................................ 16Case Management Outcomes............................................................................................................. 16

Goals and Objectives for Case Management Services........................................................................ 17Goals..................................................................................................................................... 17Objectives.............................................................................................................................. 19

Objective Documentation.................................................................................................................. 22Addendum: Client Grievances or Complaints........................................................................................ 27

Medica....................................................................................................................................... 27Complaint and Appeal Procedure............................................................................................... 27

Blue Plus (Blue Cross Blue Shield of Minnesota)............................................................................... 28UCare......................................................................................................................................... 29UCare Provider Manual: Grievances................................................................................................ 30Minnesota Health Care Programs: Health Plan Appeals State Fair Hearings and Grievances....................33

Case Manager Qualifications, Supervision & Training

Experienced Case ManagerCase Managers at Accend must have bachelor's degree in one of the behavioral sciences or related fields including, but not limited to, social work, psychology, or nursing and have at least 2,000 hours of supervised experience in the delivery of services to adults with mental illness.

Ongoing SupervisionA case manager must receive regular ongoing supervision and clinical supervision totaling 38 hours per year of which at least one hour per month must be clinical supervision regarding individual service delivery with a case management supervisor. The remaining 26 hours of supervision may be provided by a case manager with two years of experience. Group supervision may not constitute morethan one-half of the required supervision hours. Clinical supervision must be documented in the recipient record. Additional supervision requirements for Trainees and Associates are detailed below.

Case Manager TraineeA case manager with a degree without 2,000 hours of supervised experience in the delivery of services to adults with mental illness must

• receive clinical supervision regarding individual service delivery from a mental health professional at least one hour per week until the requirement of 2,000 hours of experience is met; and

• complete 40 hours of training approved by the commissioner in case management skills and the characteristics and needs of adults with serious and persistent mental illness.

Case Manager AssociateThere are various qualifying criteria defined for non-degreed Case Manager associates defined in Minnesota Statute 245.462. Case Manager associates must receive 5 hours of mentoring by a Case Management Mentor (also defined there) until they have met the criteria for becoming a Case Manager as defined in that statute.

Caseload and Frequency of Contact The caseload for a full-time equivalent case manager is 25-30 active recipients. At times the caseloadof an individual case manager may exceed 30 when recipients exceeding 30 are in a period of transition to discharge to another case manager.

Frequency of contact is determined by recipient need. Accend shall follow the DHS guidelines for billing Case Management. Case Management is billable each month if:

• at least one case management core service component is provided consistent with the ICSP; and

• the Case Manager makes at least one face-to-face contact with the recipient during the

Case Manager Qualifications, Supervision & Training

Experienced Case ManagerCase Managers at Accend must have bachelor's degree in one of the behavioral sciences or related fields including, but not limited to, social work, psychology, or nursing and have at least 2,000 hours of supervised experience in the delivery of services to adults with mental illness.

Ongoing SupervisionA case manager must receive regular ongoing supervision and clinical supervision totaling 38 hours per year of which at least one hour per month must be clinical supervision regarding individual service delivery with a case management supervisor. The remaining 26 hours of supervision may be provided by a case manager with two years of experience. Group supervision may not constitute morethan one-half of the required supervision hours. Clinical supervision must be documented in the recipient record. Additional supervision requirements for Trainees and Associates are detailed below.

Case Manager TraineeA case manager with a degree without 2,000 hours of supervised experience in the delivery of services to adults with mental illness must

• receive clinical supervision regarding individual service delivery from a mental health professional at least one hour per week until the requirement of 2,000 hours of experience is met; and

• complete 40 hours of training approved by the commissioner in case management skills and the characteristics and needs of adults with serious and persistent mental illness.

Case Manager AssociateThere are various qualifying criteria defined for non-degreed Case Manager associates defined in Minnesota Statute 245.462. Case Manager associates must receive 5 hours of mentoring by a Case Management Mentor (also defined there) until they have met the criteria for becoming a Case Manager as defined in that statute.

Caseload and Frequency of Contact The caseload for a full-time equivalent case manager is 25-30 active recipients. At times the caseloadof an individual case manager may exceed 30 when recipients exceeding 30 are in a period of transition to discharge to another case manager.

Frequency of contact is determined by recipient need. Accend shall follow the DHS guidelines for billing Case Management. Case Management is billable each month if:

• at least one case management core service component is provided consistent with the ICSP; and

• the Case Manager makes at least one face-to-face contact with the recipient during the

month; or

• the Case Manager makes at least one telephone contact with the recipient in which at least one case management core service component is provided consistent with the ICSP; and

• has made at least on qualifying face-to-face contact with the recipient within the preceding two months.

The Accend standard for face-to-face contact is at least monthly. Face-to-face contact of less than monthly is NOT an acceptable standard for the large majority of case management recipients.

Although the administrative rule allows for some flexibility and less frequent contact, this flexibility is to be applied in certain limited and appropriate situations. For example, prior to terminating case management services, the recipient and case manager might plan for less than monthly face-to-face contact to help determine the recipient’s self-sufficiency, and aptness of case closure planning.

Case Management Eligibility Screening, Admission and Discharge

Responsive Case Management ServicesIndividuals referred for Case Management services typically have immediate unmet basic needs. These may be for housing, health care, conditions related to a mental health crisis, transition from a higher level of care, or others. Screening, eligibility and insurance application should never delay work on making sure urgent basic needs are met. To ensure that we meet the immediate basic needs of referrals:

1. On the day of intake Diagnostic Assessment, complete an Intake/Basic Needs interview and prioritize action steps to see that the referred's immediate basic needs are met.

2. Whether or not recipient who has urgent basic needs is properly insured by a plan that coversCase Management, schedule an immediate follow-up appointment for to begin additional admission steps (within 1-5 days of intake, depending on the urgency of the referred's needs).This appointment should be offered in the recipient's current residence if preferred by the recipient.

3. While eligibility screening, assessment and service planning are essential steps, meet urgent basic needs of the recipient during the first 30 days, gathering information for goal-setting through dialogue and observation.

4. Coordinate with the diagnostician to see that the Diagnostic Assessment and Eligibility Screening is completed within within 7 days or sooner of the initial intake interview (unless thisis impossible because additional information is needed to confirm eligibility or verify diagnoses).

5. When the recipient's current insurance does not cover Case Management services, or when eligibility is not confirmed, document the basic needs supports you provide as Case Management Outreach (non-billable service.)

month; or

• the Case Manager makes at least one telephone contact with the recipient in which at least one case management core service component is provided consistent with the ICSP; and

• has made at least on qualifying face-to-face contact with the recipient within the preceding two months.

The Accend standard for face-to-face contact is at least monthly. Face-to-face contact of less than monthly is NOT an acceptable standard for the large majority of case management recipients.

Although the administrative rule allows for some flexibility and less frequent contact, this flexibility is to be applied in certain limited and appropriate situations. For example, prior to terminating case management services, the recipient and case manager might plan for less than monthly face-to-face contact to help determine the recipient’s self-sufficiency, and aptness of case closure planning.

Case Management Eligibility Screening, Admission and Discharge

Responsive Case Management ServicesIndividuals referred for Case Management services typically have immediate unmet basic needs. These may be for housing, health care, conditions related to a mental health crisis, transition from a higher level of care, or others. Screening, eligibility and insurance application should never delay work on making sure urgent basic needs are met. To ensure that we meet the immediate basic needs of referrals:

1. On the day of intake Diagnostic Assessment, complete an Intake/Basic Needs interview and prioritize action steps to see that the referred's immediate basic needs are met.

2. Whether or not recipient who has urgent basic needs is properly insured by a plan that coversCase Management, schedule an immediate follow-up appointment for to begin additional admission steps (within 1-5 days of intake, depending on the urgency of the referred's needs).This appointment should be offered in the recipient's current residence if preferred by the recipient.

3. While eligibility screening, assessment and service planning are essential steps, meet urgent basic needs of the recipient during the first 30 days, gathering information for goal-setting through dialogue and observation.

4. Coordinate with the diagnostician to see that the Diagnostic Assessment and Eligibility Screening is completed within within 7 days or sooner of the initial intake interview (unless thisis impossible because additional information is needed to confirm eligibility or verify diagnoses).

5. When the recipient's current insurance does not cover Case Management services, or when eligibility is not confirmed, document the basic needs supports you provide as Case Management Outreach (non-billable service.)

Criteria for EligibilityMn Statute 245.462, subdivision 20 defines eligibility for case management as follows:

For purposes of case management and community support services, a "person with serious andpersistent mental illness" means an adult who has a mental illness and meets at least one of the following criteria:

(1) the adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months;

(2) the adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months' duration within the preceding 12 months;

(3) the adult has been treated by a crisis team two or more times within the preceding 24 months;

(4) the adult:

(i) has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder,or borderline personality disorder;

(ii) indicates a significant impairment in functioning; and

(iii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;

(5) the adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult's commitment has been stayed or continued; or

(6) the adult (i) was eligible under clauses (1) to (5), but the specified time period has expired or the adult was eligible as a child under section 245.4871, subdivision 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adultis reasonably likely to have future episodes requiring inpatient or residential treatment, of a

frequency described in clause (1) or (2), unless ongoing case management or community support services are provided; or

(7) the adult was eligible as a child under section 245.4871, subdivision 6, and is age 21 or younger.

Screening for eligibility must be completed every 3 years, or at any time when a subsequent Diagnostic Assessment indicates a substantial change in Diagnosis or eligibility elements. Each time the DA is updated, the case manager must review the DA to determine if a re-screening is needed.

Use the following flowchart to determine eligibility for Case Management services.

Criteria for EligibilityMn Statute 245.462, subdivision 20 defines eligibility for case management as follows:

For purposes of case management and community support services, a "person with serious andpersistent mental illness" means an adult who has a mental illness and meets at least one of the following criteria:

(1) the adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months;

(2) the adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months' duration within the preceding 12 months;

(3) the adult has been treated by a crisis team two or more times within the preceding 24 months;

(4) the adult:

(i) has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder,or borderline personality disorder;

(ii) indicates a significant impairment in functioning; and

(iii) has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;

(5) the adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult's commitment has been stayed or continued; or

(6) the adult (i) was eligible under clauses (1) to (5), but the specified time period has expired or the adult was eligible as a child under section 245.4871, subdivision 6; and (ii) has a written opinion from a mental health professional, in the last three years, stating that the adultis reasonably likely to have future episodes requiring inpatient or residential treatment, of a

frequency described in clause (1) or (2), unless ongoing case management or community support services are provided; or

(7) the adult was eligible as a child under section 245.4871, subdivision 6, and is age 21 or younger.

Screening for eligibility must be completed every 3 years, or at any time when a subsequent Diagnostic Assessment indicates a substantial change in Diagnosis or eligibility elements. Each time the DA is updated, the case manager must review the DA to determine if a re-screening is needed.

Use the following flowchart to determine eligibility for Case Management services.

Required Assessment Elements in Case ManagementElement Deadline UpdateIntake/Basic NeedsAssessment

First contact. Continuously

Diagnostic Assessment

Prior to admission for CMGT services, and no more than 6 months prior to admission.

At least annually.

Eligibility Screening Within 7 days of a Diagnostic Assessment, or review of an external DA, recommending CaseManagement Services.

Prior to admission for CMGT services.

Every 3 years, or sooner when a subsequent Diagnostic Assessment indicates a substantial change in eligibility criteria, including diagnosis ormedical necessity for CMGT services.

LOCUS Within 30 days of Admission Every 6 months, or with any update to the FA.

Functional Assessment

Within 30 days of Admission

Updated

Every 6 months, or when the recipient experiences a substantial change in health, functioning, status, residence, or other life circumstances that impact functioning and status.

ICSP Within 30 days of Admission Every 6 months, or sooner based on recipient needs, progress, or lack thereof on the current ICSP.

Required Assessment Elements in Case ManagementElement Deadline UpdateIntake/Basic NeedsAssessment

First contact. Continuously

Diagnostic Assessment

Prior to admission for CMGT services, and no more than 6 months prior to admission.

At least annually.

Eligibility Screening Within 7 days of a Diagnostic Assessment, or review of an external DA, recommending CaseManagement Services.

Prior to admission for CMGT services.

Every 3 years, or sooner when a subsequent Diagnostic Assessment indicates a substantial change in eligibility criteria, including diagnosis ormedical necessity for CMGT services.

LOCUS Within 30 days of Admission Every 6 months, or with any update to the FA.

Functional Assessment

Within 30 days of Admission

Updated

Every 6 months, or when the recipient experiences a substantial change in health, functioning, status, residence, or other life circumstances that impact functioning and status.

ICSP Within 30 days of Admission Every 6 months, or sooner based on recipient needs, progress, or lack thereof on the current ICSP.

Essential Steps in Case Management Admissions 1. Review and confirm insurance coverage, identifying redetermination dates for insurance.

*Take proactive early steps when the deadline for redetermination for health insurance nears. A primary role of Case Management is to support recipients in maintaining crucial health care coverage: it is not acceptable that a recipient with case management loses insurance, if his or her eligibility remains the same, because he or she has failed to file paperwork or attend interviews.

2. Once the DA Interview is complete and the DA document, even if not complete, has sufficient information to establish eligibility, Case Management services may begin.

◦ Complete an Eligibility Screening by review the Diagnostic Assessment write-up and/or Psychological Evaluation and statements from mental health professionals describing the risk of hospitalization or treatment if Case Management services are not provided.

◦ If necessary in a case where the referred's history is unclear and more information is needed to establish eligibility, using necessary ROIs, obtain proof of eligibility in the form of:

▪ Hospital or treatment admissions/discharge notes;

▪ Crisis team incident reports/notes;

▪ Commitment/stay of commitment documentation; or

▪ Other qualifying criteria.

◦ Record the start date for case management as the first date of face-to-face case management service following completion of the eligibility screening. (This may be the same day as the screening is complete.) Change the client's status to Initiating for Case Management.

◦ Ensure that the DA is completed by the deadline of 7 calendar days following the interview.

3. Develop and prioritize long-term goals with the recipient.

4. Within 30 days of admission, complete the FA and LOCUS, with an emphasis on identifying strengths, resources and barriers to long term goals, needed health care, behavioral health care, social services, vocational, educational and other supports.

5. Develop short-term CMGT objectives (steps to be accomplished in the next 3-12 months to move closer to goal achievement.

6. Create the ICSP from goals and objectives within 30 days of the first date of service (admission).

7. Once the initial ICSP is complete, change the status of the recipient to Active.

Essential Steps in Case Management Admissions 1. Review and confirm insurance coverage, identifying redetermination dates for insurance.

*Take proactive early steps when the deadline for redetermination for health insurance nears. A primary role of Case Management is to support recipients in maintaining crucial health care coverage: it is not acceptable that a recipient with case management loses insurance, if his or her eligibility remains the same, because he or she has failed to file paperwork or attend interviews.

2. Once the DA Interview is complete and the DA document, even if not complete, has sufficient information to establish eligibility, Case Management services may begin.

◦ Complete an Eligibility Screening by review the Diagnostic Assessment write-up and/or Psychological Evaluation and statements from mental health professionals describing the risk of hospitalization or treatment if Case Management services are not provided.

◦ If necessary in a case where the referred's history is unclear and more information is needed to establish eligibility, using necessary ROIs, obtain proof of eligibility in the form of:

▪ Hospital or treatment admissions/discharge notes;

▪ Crisis team incident reports/notes;

▪ Commitment/stay of commitment documentation; or

▪ Other qualifying criteria.

◦ Record the start date for case management as the first date of face-to-face case management service following completion of the eligibility screening. (This may be the same day as the screening is complete.) Change the client's status to Initiating for Case Management.

◦ Ensure that the DA is completed by the deadline of 7 calendar days following the interview.

3. Develop and prioritize long-term goals with the recipient.

4. Within 30 days of admission, complete the FA and LOCUS, with an emphasis on identifying strengths, resources and barriers to long term goals, needed health care, behavioral health care, social services, vocational, educational and other supports.

5. Develop short-term CMGT objectives (steps to be accomplished in the next 3-12 months to move closer to goal achievement.

6. Create the ICSP from goals and objectives within 30 days of the first date of service (admission).

7. Once the initial ICSP is complete, change the status of the recipient to Active.

Discharge ProceduresCase Management recipients may be discharged for the following reasons.

Administrative DischargeThe recipient has:

• Become irreparably and permanently uninsured for AMH-TCM services, and connected to service and support resources elsewhere.

• Moved out of state.

• Has moved or we have lost contact for a period of one month and contact is not possible because the client does not have a phone and we have no known address, or any collateral contact persons associated with the person.

• Moved to another county in the state where we do not have a Case Management presence, with services continuing for at least 60 days and until he or she connected to services in the new county, whichever comes last Before discharging for a move, complete all of the followingsteps.

◦ Assure the recipient that we will continue to provide Case Management services to him or her in the new residence for at least 60 days, or until he or she is connected with services in the new location.

◦ Do not discharge a recipient who moves to an excluded time facility such as a treatment facility or short-term rehabilitation or nursing facility. Continue services in this case.

◦ Do not discharge the recipient if the move is temporary (less than 60 days) and the recipient will return to his or her original county.

• Chooses a service that is incompatible with AMH-TCM services (such as Behavioral Health Home or Assertive Community Treatment).

• Has been incarcerated for a period of 6 months or more.

• Has been civilly committed and is receiving case management services from the county.

• Has transferred to case management services with another provider.

• Has requested discharge for another, documented reason.

• Is no longer eligible for AMH-TCM services for other administrative reasons.

Clinical DischargeThe recipient:

• Has achieved his or her goals/outcomes and reaches a level of psychiatric stability and statusso that Case Management services are no longer necessary, and has participated in a voluntary successful discharge process, including connections to formal and informal ongoing supports

Discharge ProceduresCase Management recipients may be discharged for the following reasons.

Administrative DischargeThe recipient has:

• Become irreparably and permanently uninsured for AMH-TCM services, and connected to service and support resources elsewhere.

• Moved out of state.

• Has moved or we have lost contact for a period of one month and contact is not possible because the client does not have a phone and we have no known address, or any collateral contact persons associated with the person.

• Moved to another county in the state where we do not have a Case Management presence, with services continuing for at least 60 days and until he or she connected to services in the new county, whichever comes last Before discharging for a move, complete all of the followingsteps.

◦ Assure the recipient that we will continue to provide Case Management services to him or her in the new residence for at least 60 days, or until he or she is connected with services in the new location.

◦ Do not discharge a recipient who moves to an excluded time facility such as a treatment facility or short-term rehabilitation or nursing facility. Continue services in this case.

◦ Do not discharge the recipient if the move is temporary (less than 60 days) and the recipient will return to his or her original county.

• Chooses a service that is incompatible with AMH-TCM services (such as Behavioral Health Home or Assertive Community Treatment).

• Has been incarcerated for a period of 6 months or more.

• Has been civilly committed and is receiving case management services from the county.

• Has transferred to case management services with another provider.

• Has requested discharge for another, documented reason.

• Is no longer eligible for AMH-TCM services for other administrative reasons.

Clinical DischargeThe recipient:

• Has achieved his or her goals/outcomes and reaches a level of psychiatric stability and statusso that Case Management services are no longer necessary, and has participated in a voluntary successful discharge process, including connections to formal and informal ongoing supports

• No longer qualifies based on a Diagnostic Assessment and Eligibility Screening using the eligibility requirements above during an recently-updated Diagnostic assessment that determinescase management services are no longer necessary, and has been informed of the finding, and received information about appeal rights

• Has repeatedly declined to participate in assessment updates to maintain ongoing eligibility determination, with documented evidence of effort to schedule and conduct the session, including offering to provide the assessment at home as needed, arranging transportation, etc.

• Has disengaged from services for a period of six months or more, with documented efforts to contact, schedule, re-engage and coordinate with other service providers within and outside the agency, with contact effort by someone other than the assigned case manager to investigate the reasons for discharge, and an offer of a transfer to another provider if desired

◦ Make efforts to contact the recipient through other service providers or the referral source.

◦ If contact is lost, send a letter to the recipient's last known address, offering services and inviting the recipient to re-engage at any time.

◦ Move the recipient to Closing status if disengaged for a period of two months.

◦ Close the case by setting status to Previous after 6 months, informing the recipient of discharge with a 2nd letter to the recipient's last known address. The letter should reassurethe recipient that he or she may contact us at any time in the future for services.

• Has needs that will be met better by another agency, and has been referred and admitted forcase management services with that provider

• Other clinical reasons for discharge

Discharge DocumentationDischarge procedures including all of the following steps and documentation:

• A discharge Progress Review, with clinical notes describing the reasons for discharge

• An updated (discharge) client Status assessment

• An updated (discharge) LOCUS

• A final Case Mgt Referral Intake Discharge progress note by the case manager describing the reason for discharge, including details on referrals made

• For discharges other than successful, voluntary discharges, a Clinical Supervision Note, or a Case Mgt Referral Intake Discharge progress note by the Clinic Manager describing and approving the reason for discharge. These notes should describe:

◦ the reason for discharge,

◦ notes on efforts made to avoid discharge (engagement, assessment, coordination, other),

• For involuntary discharges based on a finding of ineligibility, documentation of delivery of a Notice of Appeal Rights to the client.

• No longer qualifies based on a Diagnostic Assessment and Eligibility Screening using the eligibility requirements above during an recently-updated Diagnostic assessment that determinescase management services are no longer necessary, and has been informed of the finding, and received information about appeal rights

• Has repeatedly declined to participate in assessment updates to maintain ongoing eligibility determination, with documented evidence of effort to schedule and conduct the session, including offering to provide the assessment at home as needed, arranging transportation, etc.

• Has disengaged from services for a period of six months or more, with documented efforts to contact, schedule, re-engage and coordinate with other service providers within and outside the agency, with contact effort by someone other than the assigned case manager to investigate the reasons for discharge, and an offer of a transfer to another provider if desired

◦ Make efforts to contact the recipient through other service providers or the referral source.

◦ If contact is lost, send a letter to the recipient's last known address, offering services and inviting the recipient to re-engage at any time.

◦ Move the recipient to Closing status if disengaged for a period of two months.

◦ Close the case by setting status to Previous after 6 months, informing the recipient of discharge with a 2nd letter to the recipient's last known address. The letter should reassurethe recipient that he or she may contact us at any time in the future for services.

• Has needs that will be met better by another agency, and has been referred and admitted forcase management services with that provider

• Other clinical reasons for discharge

Discharge DocumentationDischarge procedures including all of the following steps and documentation:

• A discharge Progress Review, with clinical notes describing the reasons for discharge

• An updated (discharge) client Status assessment

• An updated (discharge) LOCUS

• A final Case Mgt Referral Intake Discharge progress note by the case manager describing the reason for discharge, including details on referrals made

• For discharges other than successful, voluntary discharges, a Clinical Supervision Note, or a Case Mgt Referral Intake Discharge progress note by the Clinic Manager describing and approving the reason for discharge. These notes should describe:

◦ the reason for discharge,

◦ notes on efforts made to avoid discharge (engagement, assessment, coordination, other),

• For involuntary discharges based on a finding of ineligibility, documentation of delivery of a Notice of Appeal Rights to the client.

Recipient or Referral Appeal of Eligibility or Discharge DecisionsAll recipients have a right to appeal decisions to discharge or deny them for Case Management services based on an eligibility screening, progress review, or assessment. At any time a recipient is informed of a decision to discharge, inform the client of his or her right to appeal and document thisin the recipient's file.

To make the appeal process as easy as possible, recipients may appeal decisions by calling or writingto the agency Clinical Director, Program Director, or Executive Director.

As soon as any one of these Directors is made aware of the appeal, they will document it in the recipients file, gather information, investigate, make a final decision, and communicate that decision tothe recipient within one week of the appeal.

If more information and is needed to answer the appeal (for example the discharge decision has beenmade as a result of an external diagnostic assessment) Director who is handling the appeal will communicate this to the client within one week of the appeal and identify a new date by which the decision will be made.

If a recipient has been receiving services and is found no longer eligible, services will continue during the appeal until a final decision has been reached.

If a decision to deny services is based on a Diagnostic Assessment that finds the recipient not eligible, the recipient will also be informed of his or her right to seek a second opinion on that Diagnostic Assessment.

If, following an appeal, the decision to discharge or deny services based on eligibility is confirmed, the Director handling the appeal will inform the recipient of his or her right to further appeal the decision to his or her health plan, to his or her county of residence, or to the local Ombudsman for Mental Health.

Client Grievances or ComplaintsAccend services is committed to the highest possible quality of services. Our goal is to develop and maintain an open and trusting partnership with each of the people we serve. We encourage them to speak directly to staff members about needs and concerns.

If someone finds that a staff member is unresponsive to needs or concerns, feels mistreated in any way or has a complaint, they may contact any supervisor, who will listen to these concerns and workto resolve them. Our efforts to resolve the problem may include the following, with permission:

• facilitate a meeting with the person served and provider staff to find a solution;

• Speak to the provider staff about the complaint and work out a solution;

• bring the concern to others to find a solution;

• if the problem with the current provider cannot be resolved, refer facilitate a transfer to

Recipient or Referral Appeal of Eligibility or Discharge DecisionsAll recipients have a right to appeal decisions to discharge or deny them for Case Management services based on an eligibility screening, progress review, or assessment. At any time a recipient is informed of a decision to discharge, inform the client of his or her right to appeal and document thisin the recipient's file.

To make the appeal process as easy as possible, recipients may appeal decisions by calling or writingto the agency Clinical Director, Program Director, or Executive Director.

As soon as any one of these Directors is made aware of the appeal, they will document it in the recipients file, gather information, investigate, make a final decision, and communicate that decision tothe recipient within one week of the appeal.

If more information and is needed to answer the appeal (for example the discharge decision has beenmade as a result of an external diagnostic assessment) Director who is handling the appeal will communicate this to the client within one week of the appeal and identify a new date by which the decision will be made.

If a recipient has been receiving services and is found no longer eligible, services will continue during the appeal until a final decision has been reached.

If a decision to deny services is based on a Diagnostic Assessment that finds the recipient not eligible, the recipient will also be informed of his or her right to seek a second opinion on that Diagnostic Assessment.

If, following an appeal, the decision to discharge or deny services based on eligibility is confirmed, the Director handling the appeal will inform the recipient of his or her right to further appeal the decision to his or her health plan, to his or her county of residence, or to the local Ombudsman for Mental Health.

Client Grievances or ComplaintsAccend services is committed to the highest possible quality of services. Our goal is to develop and maintain an open and trusting partnership with each of the people we serve. We encourage them to speak directly to staff members about needs and concerns.

If someone finds that a staff member is unresponsive to needs or concerns, feels mistreated in any way or has a complaint, they may contact any supervisor, who will listen to these concerns and workto resolve them. Our efforts to resolve the problem may include the following, with permission:

• facilitate a meeting with the person served and provider staff to find a solution;

• Speak to the provider staff about the complaint and work out a solution;

• bring the concern to others to find a solution;

• if the problem with the current provider cannot be resolved, refer facilitate a transfer to

another provider.

Individuals may put the grievance in writing to help us better understand the problem and how to solve it.

Supervisors who can be contacted to resolve problems, complaints or grievances include any of the following:

• The Practitioner Team Lead

• The Team Clinical Supervisor

• The Clinical Director

• The Executive Director

Client Grievances or Complaints: Health Insurance Programs and ProvidersSee Addendum: Client Grievances or Complaints at the end of this policy for instructions to recipientsfor addressing complaints or grievances related to case management services, or other health care, access, services with their insurance provider. Provide assistance to clients as needed with this process.

Case Management Service Provision Standards 1. Contact all recipients by phone or in person during the first week of each month to assess

needs and make a plan for the month (unless progress notes from the preceding month have specifically identified the plan.)

2. See recipients face-to-face at least once twice per month and more often as needed. If no face-to-face contact, a telephone contact (actual contact, not a phone message) must occur.

3. Arrange for services the recipient needs.

4. Monitor and coordinate existing services.

• Where the recipient also receives ARMHS, assure that ARMHS are provided at the levelsin the plan. When this is not happening, investigate by talking with the recipient, the practitioner, the Treatment Director and Clinical Consultant/Supervisor as necessary.

• For recipients with services elsewhere, obtain copies of Treatment Plans, residential support plans and other documents describing services. Review these to assure that they substantially match the goals and objectives in the recipient's ICSP. Provide the ICSP to the provider with an appropriate signed release of information.

• Arrange for coordination of services with the recipient's primary physician.

▪ For recipients taking psychotropic medications, arrange for a standardized assessmentby a physician of the recipient’s choice of side effects related to the administration of the recipient’s psychotropic medications.

5. Re-assess needs and update assessments and plans as needed (not just for compliance.) Times when a recipient's assessments should be updated include, but are not limited to:

another provider.

Individuals may put the grievance in writing to help us better understand the problem and how to solve it.

Supervisors who can be contacted to resolve problems, complaints or grievances include any of the following:

• The Practitioner Team Lead

• The Team Clinical Supervisor

• The Clinical Director

• The Executive Director

Client Grievances or Complaints: Health Insurance Programs and ProvidersSee Addendum: Client Grievances or Complaints at the end of this policy for instructions to recipientsfor addressing complaints or grievances related to case management services, or other health care, access, services with their insurance provider. Provide assistance to clients as needed with this process.

Case Management Service Provision Standards 1. Contact all recipients by phone or in person during the first week of each month to assess

needs and make a plan for the month (unless progress notes from the preceding month have specifically identified the plan.)

2. See recipients face-to-face at least once twice per month and more often as needed. If no face-to-face contact, a telephone contact (actual contact, not a phone message) must occur.

3. Arrange for services the recipient needs.

4. Monitor and coordinate existing services.

• Where the recipient also receives ARMHS, assure that ARMHS are provided at the levelsin the plan. When this is not happening, investigate by talking with the recipient, the practitioner, the Treatment Director and Clinical Consultant/Supervisor as necessary.

• For recipients with services elsewhere, obtain copies of Treatment Plans, residential support plans and other documents describing services. Review these to assure that they substantially match the goals and objectives in the recipient's ICSP. Provide the ICSP to the provider with an appropriate signed release of information.

• Arrange for coordination of services with the recipient's primary physician.

▪ For recipients taking psychotropic medications, arrange for a standardized assessmentby a physician of the recipient’s choice of side effects related to the administration of the recipient’s psychotropic medications.

5. Re-assess needs and update assessments and plans as needed (not just for compliance.) Times when a recipient's assessments should be updated include, but are not limited to:

• The recipient moves to a substantially different residential setting (from/to a higher level of care to a lower/higher one);

• The recipient gets or loses a job;

• The recipient starts or ends school;

• The recipient has a substantial change in household or family status;

• The recipient experiences other substantial stressors or life changes.

6. Document and monitor progress towards goals and objectives, reviewing and updating the planwhenever needed (not just when due by rule.) Each progress note should contain a plan for what will happen next, including:

• what the recipient will do;

• what the case manager will do;

• when the case manager will see the recipient next; and

• other pertinent planning information.

Cultural Awareness in Service DeliveryCultural awareness and sensitivity is an essential element of person-centered services. Cultural and spiritual considerations are broad, and may include many elements, and are not limited only to individuals of a clearly minority culture or populations. Providers must also consider the fact that evenif recipients have left a religion or may be removed in time and distance from the culture of their childhood, many of the impacts of these cultures remain as a significant influence in their lives.

Culture is a pattern of ideas, customs and behaviors shared by a particular people or society. It is constantly evolving. Culture affects perceptions of health, illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer. Some core elements to consider (but far from a comprehensive list) are:

Interpersonal Interactions, such as• Personal space

• Eye contact

• Intonation, tone of voice

• Openness versus privacy in communication about one's self, needs, conditions, etc

Religious Beliefs and Cultural Viewpoints on Health and Wellness• Beliefs about the use of medications, invasive medical procedures

• Prayer and spiritual healing practices

• Holy Days and practices associated with them

• Beliefs about mental illness, causes, and stigma

Cultural Practices and Traditions• Treatment of elders

• The recipient moves to a substantially different residential setting (from/to a higher level of care to a lower/higher one);

• The recipient gets or loses a job;

• The recipient starts or ends school;

• The recipient has a substantial change in household or family status;

• The recipient experiences other substantial stressors or life changes.

6. Document and monitor progress towards goals and objectives, reviewing and updating the planwhenever needed (not just when due by rule.) Each progress note should contain a plan for what will happen next, including:

• what the recipient will do;

• what the case manager will do;

• when the case manager will see the recipient next; and

• other pertinent planning information.

Cultural Awareness in Service DeliveryCultural awareness and sensitivity is an essential element of person-centered services. Cultural and spiritual considerations are broad, and may include many elements, and are not limited only to individuals of a clearly minority culture or populations. Providers must also consider the fact that evenif recipients have left a religion or may be removed in time and distance from the culture of their childhood, many of the impacts of these cultures remain as a significant influence in their lives.

Culture is a pattern of ideas, customs and behaviors shared by a particular people or society. It is constantly evolving. Culture affects perceptions of health, illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer. Some core elements to consider (but far from a comprehensive list) are:

Interpersonal Interactions, such as• Personal space

• Eye contact

• Intonation, tone of voice

• Openness versus privacy in communication about one's self, needs, conditions, etc

Religious Beliefs and Cultural Viewpoints on Health and Wellness• Beliefs about the use of medications, invasive medical procedures

• Prayer and spiritual healing practices

• Holy Days and practices associated with them

• Beliefs about mental illness, causes, and stigma

Cultural Practices and Traditions• Treatment of elders

• Diet

• Parenting and child-rearing styles

• Definition of family

• Gender roles

Other Cultural Considerations• Sensitivity to racism and ethnocentrism experienced by the person

• Stigma about mental illness within a given culture

• Acculturation (adjustment or adaptation to a new culture, for example, but not limited to, acculturation to US life by immigrant populations)

• Cultural values and the ways in which culture shapes family relationships, ethics, core beliefs, and communication styles

• Consumerism

• Language barriers

Case Managers must assess and include in the Functional Assessment, all cultural and spiritual considerations for treatment. Complete this section of the 6X6 Functional Assessment, and identify cultural and spiritual considerations for treatment in the Treatment Rationale in each domain, and Methods as applicable in all ICSP objectives.

Core AMH-TCM Services Defined The AMH-TCM components often overlap and may be providedconcurrently. The recipient and case manager are constantly:

• assessing the individual’s needs and goals and impact ofmental illness, utilizing the individual’s strengths andprogress;

• clarifying goal-related plans and steps and updating theICSP, thinking of new resources;

• referring and linking to resources/supports/services,coordinating with partners in the recipient’s plan;

• monitoring the effectiveness of theresources/supports/services being utilized;

• reviewing the need for AMH-TCM services; and

• discussing the individual’s progress toward goals and recovery.

Assessment An AMH-TCM assessment has four parts:

1. Review the diagnostic assessment.

2. Assess with recipient for strengths, resources, supports, needs, functioning, health problems

and conditions, safety, vulnerability, and injury risk. Assessment should include family members,

• Diet

• Parenting and child-rearing styles

• Definition of family

• Gender roles

Other Cultural Considerations• Sensitivity to racism and ethnocentrism experienced by the person

• Stigma about mental illness within a given culture

• Acculturation (adjustment or adaptation to a new culture, for example, but not limited to, acculturation to US life by immigrant populations)

• Cultural values and the ways in which culture shapes family relationships, ethics, core beliefs, and communication styles

• Consumerism

• Language barriers

Case Managers must assess and include in the Functional Assessment, all cultural and spiritual considerations for treatment. Complete this section of the 6X6 Functional Assessment, and identify cultural and spiritual considerations for treatment in the Treatment Rationale in each domain, and Methods as applicable in all ICSP objectives.

Core AMH-TCM Services Defined The AMH-TCM components often overlap and may be providedconcurrently. The recipient and case manager are constantly:

• assessing the individual’s needs and goals and impact ofmental illness, utilizing the individual’s strengths andprogress;

• clarifying goal-related plans and steps and updating theICSP, thinking of new resources;

• referring and linking to resources/supports/services,coordinating with partners in the recipient’s plan;

• monitoring the effectiveness of theresources/supports/services being utilized;

• reviewing the need for AMH-TCM services; and

• discussing the individual’s progress toward goals and recovery.

Assessment An AMH-TCM assessment has four parts:

1. Review the diagnostic assessment.

2. Assess with recipient for strengths, resources, supports, needs, functioning, health problems

and conditions, safety, vulnerability, and injury risk. Assessment should include family members,

significant others, providers as possible. This assessment is completed in the form of a Functional Assessment.

3. Screen for substance use/abuse

4. Review documentation and updating documentation of recipient’s status, cultural considerations,and functional description in all the functional assessment domains specified in Minnesota Statute, and complete a LOCUS assessment to determine resources and resource intensity needs.

It is important that the functional assessment (FA), defined in Minnesota Statute, include the recipient’s health care coverage, access to preventative and routine health care, individual participationin recommended health care treatment, and individual health lifestyle.

The case manager must complete a Functional Assessment within 30 days of the first meeting with the recipient, and at least every 180 days after the development of the ICSP. The FA must be developed with input from the recipient, and (with permission of recipient) service providers and significant members of the recipient’s support network.

Planning A case manager and the recipient – with input from other service providers and significant members of the recipient’s support network – develop an Individual Community Support Plan (ICSP) that includesthe following

• goals of recipient and the specific services;

• activities for accomplishing each goal;

• schedule for each activity; and

• frequency of face-to-face contact with case manager.

The case manager must complete the ICSP within 30 days of the first meeting with the recipient, and must update the ICSP at least every 180 days. The case manager should develop the ICSP

Referral and Linkage Based on review of the Diagnostic Assessment, Functional Assessment, LOCUS, and the recipient's own treatment and recovery goals, the Case Manager's primary role in referral and linkage is review the need for mental health, health care, education, vocational, financial and other services, linking therecipient to these services, and then monitoring the quality and effectiveness of these services, and the recipient's participation in and satisfaction with them.

A primary focus of referral and linkage is to remove barriers separating recipients from the communityand to replace segregation with true community integration. To do so, case managers must be familiar with the community and key contact persons within particular agencies (housing, education, vocational, financial, health care services and other providers.

Referral and linkage involves interactions with the recipient to:

significant others, providers as possible. This assessment is completed in the form of a Functional Assessment.

3. Screen for substance use/abuse

4. Review documentation and updating documentation of recipient’s status, cultural considerations,and functional description in all the functional assessment domains specified in Minnesota Statute, and complete a LOCUS assessment to determine resources and resource intensity needs.

It is important that the functional assessment (FA), defined in Minnesota Statute, include the recipient’s health care coverage, access to preventative and routine health care, individual participationin recommended health care treatment, and individual health lifestyle.

The case manager must complete a Functional Assessment within 30 days of the first meeting with the recipient, and at least every 180 days after the development of the ICSP. The FA must be developed with input from the recipient, and (with permission of recipient) service providers and significant members of the recipient’s support network.

Planning A case manager and the recipient – with input from other service providers and significant members of the recipient’s support network – develop an Individual Community Support Plan (ICSP) that includesthe following

• goals of recipient and the specific services;

• activities for accomplishing each goal;

• schedule for each activity; and

• frequency of face-to-face contact with case manager.

The case manager must complete the ICSP within 30 days of the first meeting with the recipient, and must update the ICSP at least every 180 days. The case manager should develop the ICSP

Referral and Linkage Based on review of the Diagnostic Assessment, Functional Assessment, LOCUS, and the recipient's own treatment and recovery goals, the Case Manager's primary role in referral and linkage is review the need for mental health, health care, education, vocational, financial and other services, linking therecipient to these services, and then monitoring the quality and effectiveness of these services, and the recipient's participation in and satisfaction with them.

A primary focus of referral and linkage is to remove barriers separating recipients from the communityand to replace segregation with true community integration. To do so, case managers must be familiar with the community and key contact persons within particular agencies (housing, education, vocational, financial, health care services and other providers.

Referral and linkage involves interactions with the recipient to:

• connect the recipient with informal natural supports;

• link the recipient with the local community, resources, and service providers; and

• refer the recipient to available health treatment and rehabilitation services.

Monitoring and Coordination A significant portion of the case manager’s monitoring and coordination activities are done over the phone with other providers, resources, and service representatives. Monitoring and coordination servesfour global purposes:

1. Ensure service coordination by reviewing programs and services for accountability, assuring thateveryone is addressing the same purposes stated in the ICSP so that the recipient is not exposed to discontinuous or conflicting interventions and services.

2. Determine achievement of the goals/objectives in the recipient’s ICSP to see if goals are beingachieved according to the ICSP’s projected timeline(s) and that they continue to fit the recipient’s needs.

3. Determine service and support outcomes through ongoing observations, which can trigger reconsideration of the plan and it’s recommended interventions when the ICSP is not accomplishing its desired effects.

4. Identify emerging new needs by staying in touch with the recipient to identify problems, modifyplans, and ensuring that the recipient has resources to complete goals.

Internal Service Coordination and MonitoringWhen recipient's receive other services at Accend, follow these steps to assure engagement, quality and effectiveness of these services.

1. At least twice monthly, use the Custom Time Report in TabsTM to view the services the recipient has received and is scheduled to receive.

◦ Open the recipient's electronic file, navigate to Schedules and Reports, and select Client Time Report.

◦ Select a date range. The range may include future dates to view scheduled services.

◦ Examine the report to see that the recipient is receiving planned services.

◦ Where there are frequent cancellations, disengagement, or other reasons why the recipient has not received planned services, follow up with the recipient and other providers immediately.

2. For recipients receiving ARMHS or Psychotherapy, coordinate communication with the full team to review progress and engagement in services:

◦ each time assessments and treatment plans are updated;

◦ at any time engagement or progress in any service appears stalled;

• connect the recipient with informal natural supports;

• link the recipient with the local community, resources, and service providers; and

• refer the recipient to available health treatment and rehabilitation services.

Monitoring and Coordination A significant portion of the case manager’s monitoring and coordination activities are done over the phone with other providers, resources, and service representatives. Monitoring and coordination servesfour global purposes:

1. Ensure service coordination by reviewing programs and services for accountability, assuring thateveryone is addressing the same purposes stated in the ICSP so that the recipient is not exposed to discontinuous or conflicting interventions and services.

2. Determine achievement of the goals/objectives in the recipient’s ICSP to see if goals are beingachieved according to the ICSP’s projected timeline(s) and that they continue to fit the recipient’s needs.

3. Determine service and support outcomes through ongoing observations, which can trigger reconsideration of the plan and it’s recommended interventions when the ICSP is not accomplishing its desired effects.

4. Identify emerging new needs by staying in touch with the recipient to identify problems, modifyplans, and ensuring that the recipient has resources to complete goals.

Internal Service Coordination and MonitoringWhen recipient's receive other services at Accend, follow these steps to assure engagement, quality and effectiveness of these services.

1. At least twice monthly, use the Custom Time Report in TabsTM to view the services the recipient has received and is scheduled to receive.

◦ Open the recipient's electronic file, navigate to Schedules and Reports, and select Client Time Report.

◦ Select a date range. The range may include future dates to view scheduled services.

◦ Examine the report to see that the recipient is receiving planned services.

◦ Where there are frequent cancellations, disengagement, or other reasons why the recipient has not received planned services, follow up with the recipient and other providers immediately.

2. For recipients receiving ARMHS or Psychotherapy, coordinate communication with the full team to review progress and engagement in services:

◦ each time assessments and treatment plans are updated;

◦ at any time engagement or progress in any service appears stalled;

◦ when the recipient experiences a substantial change in status (residence, employment, family, or other), or following significant health care or mental health events; or

◦ at any time substantial progress indicates that modifications to the plan might be warranted.

3. When functioning is a barrier to goals, the ICSP spells out the longer-term, or ultimate, goals and outcomes, and connects the recipient to supports, including ARMHS to remove functional barriers. For recipients who receive ARMHS, the Case Manager must ensure that the ARMHS Treatment Planis coordinated with and supports the goals and objectives of Case Management. These two plans should closely coincide, driven by the ICSP. The ARMHS Treatment Plan supports these goals and objectives with a focus on more detailed treatment, skill-building and behavior change.

4. When recipients also receive psychotherapy, the therapy plan should primarily drive other services and be closely coordinated with both the ICSP and ARMHS Treatment plan.

5. When recipients disengage from Case Management services but remain connected to other services, coordinate with those providers to explore the reasons why the recipient has disengaged.

Documenting Service Coordination

Please use Case Management Service Coordination for ongoing monitoring and coordination of internal and external health and mental health care services, for activities that are not face-to-face with clients, as follows:

Coordinating internal or external services. Includes reading assessments, service plans, time reports ornotes, contacting or meeting with providers, following up on engagement or quality improvement issues, or other service coordination activities.

• At least monthly as you review engagement in and quality of other services the client receives.

• More frequently if you are investigating/solving problems with client satisfaction or engagementwith services.

• Prior to service plan updates for ARMHS, indicating you have read and coordinated with the ARMHS Progress Review and new Service Plan.

• Prior to discharge from any other service.

• When a client has disengaged from another internal service (ARMHS or Psychotherapy) for a period of one month, this note should proactively precede any file/discharge note by the other internal provider.

• At other times related to services the client receives from other providers including health, mental health, residential, vocational, financial supports, and other.

Case Management Services During Facility PlacementWhen a recipient of Case Management requires residential treatment or facility placement, Case Managers play a central role in planning placement, identifying outcomes, assuring adequate care andtreatment, and planning discharge. Case Management activities when helping a recipient prepare for placement and receive high quality treatment include, but are not limited to:

◦ when the recipient experiences a substantial change in status (residence, employment, family, or other), or following significant health care or mental health events; or

◦ at any time substantial progress indicates that modifications to the plan might be warranted.

3. When functioning is a barrier to goals, the ICSP spells out the longer-term, or ultimate, goals and outcomes, and connects the recipient to supports, including ARMHS to remove functional barriers. For recipients who receive ARMHS, the Case Manager must ensure that the ARMHS Treatment Planis coordinated with and supports the goals and objectives of Case Management. These two plans should closely coincide, driven by the ICSP. The ARMHS Treatment Plan supports these goals and objectives with a focus on more detailed treatment, skill-building and behavior change.

4. When recipients also receive psychotherapy, the therapy plan should primarily drive other services and be closely coordinated with both the ICSP and ARMHS Treatment plan.

5. When recipients disengage from Case Management services but remain connected to other services, coordinate with those providers to explore the reasons why the recipient has disengaged.

Documenting Service Coordination

Please use Case Management Service Coordination for ongoing monitoring and coordination of internal and external health and mental health care services, for activities that are not face-to-face with clients, as follows:

Coordinating internal or external services. Includes reading assessments, service plans, time reports ornotes, contacting or meeting with providers, following up on engagement or quality improvement issues, or other service coordination activities.

• At least monthly as you review engagement in and quality of other services the client receives.

• More frequently if you are investigating/solving problems with client satisfaction or engagementwith services.

• Prior to service plan updates for ARMHS, indicating you have read and coordinated with the ARMHS Progress Review and new Service Plan.

• Prior to discharge from any other service.

• When a client has disengaged from another internal service (ARMHS or Psychotherapy) for a period of one month, this note should proactively precede any file/discharge note by the other internal provider.

• At other times related to services the client receives from other providers including health, mental health, residential, vocational, financial supports, and other.

Case Management Services During Facility PlacementWhen a recipient of Case Management requires residential treatment or facility placement, Case Managers play a central role in planning placement, identifying outcomes, assuring adequate care andtreatment, and planning discharge. Case Management activities when helping a recipient prepare for placement and receive high quality treatment include, but are not limited to:

Preparing for Treatment

1. With the recipient, identify treatment outcomes for the placement prior to admission.

2. Arrange in advance for updates to all assessments due prior to or during treatment. With authorization from the recipient and provide up-to-date assessment information to the treatment facility that will help in treatment planning.

3. Arrange for transportation to, and care of housing, pets, etc. during treatment.

4. Attend and facilitate admission and treatment planning conferences as applicable.

5. Obtain releases of information for communication with the facility and arrange for written and/or verbal updates on progress during treatment.

6. If needed, plan for your own travel to the facility and lodging if necessary. (Telehealth is allowed for Case Management services and may be a future option for individuals placed at long distances from the office.)

Monitoring Treatment and Discharge

1. At regular intervals, contact treatment staff and the recipient for updates on treatment progress.

2. As discharge nears, attend discharge planning conferences.

3. Make arrangements for transportation, post-treatment housing, aftercare and other recipient post-discharge needs as applicable.

Recording Collateral ContactsCase Managers should record contact information, using the Contacts tab in Client Information for allpaid and natural support persons, including, but not limited to:

• Health care, treatment, and social services providers,

• Family members and guardians,

• Vocational, residential, and other educational providers and counselors.

Case Management OutcomesOutcomes in Case Management must be person-centered. These begin with the client's own Recovery Vision, Personal, and Treatment Goals, developed in partnership with the client by the Case Manager. Specifics for how to write person-centered and SMART goals follow. Generally speaking, however, CaseManagement outcomes fall into the following general categories:

• improved psychiatric stability (improved symptom management skills, reduced use of crisis supports, hospitalization and other interventions, or use of drugs and alcohol when symptoms are not well-managed);

• improved functioning where mental health symptoms and overall health have impaired functioning in any of the domains in the functional assessment;

Preparing for Treatment

1. With the recipient, identify treatment outcomes for the placement prior to admission.

2. Arrange in advance for updates to all assessments due prior to or during treatment. With authorization from the recipient and provide up-to-date assessment information to the treatment facility that will help in treatment planning.

3. Arrange for transportation to, and care of housing, pets, etc. during treatment.

4. Attend and facilitate admission and treatment planning conferences as applicable.

5. Obtain releases of information for communication with the facility and arrange for written and/or verbal updates on progress during treatment.

6. If needed, plan for your own travel to the facility and lodging if necessary. (Telehealth is allowed for Case Management services and may be a future option for individuals placed at long distances from the office.)

Monitoring Treatment and Discharge

1. At regular intervals, contact treatment staff and the recipient for updates on treatment progress.

2. As discharge nears, attend discharge planning conferences.

3. Make arrangements for transportation, post-treatment housing, aftercare and other recipient post-discharge needs as applicable.

Recording Collateral ContactsCase Managers should record contact information, using the Contacts tab in Client Information for allpaid and natural support persons, including, but not limited to:

• Health care, treatment, and social services providers,

• Family members and guardians,

• Vocational, residential, and other educational providers and counselors.

Case Management OutcomesOutcomes in Case Management must be person-centered. These begin with the client's own Recovery Vision, Personal, and Treatment Goals, developed in partnership with the client by the Case Manager. Specifics for how to write person-centered and SMART goals follow. Generally speaking, however, CaseManagement outcomes fall into the following general categories:

• improved psychiatric stability (improved symptom management skills, reduced use of crisis supports, hospitalization and other interventions, or use of drugs and alcohol when symptoms are not well-managed);

• improved functioning where mental health symptoms and overall health have impaired functioning in any of the domains in the functional assessment;

• improved overall health;

• improved status (independence, housing, employment, education, legal status, other);

• improved (paid and natural) support networks that the client can use and rely on during difficult times or in crisis;

• improved engagement in medically necessary or preventative mental health and health care services; and

• reduced overall healthcare costs.

Goals and Objectives for Case Management Services

GoalsThe case manager helps the recipient identify goals and to transform intangible or negatively-stated (what I don't want) goals into goals that are positive, achievable and tangible. SMART goals are:

Specific: The goals statement describes a specifically measurable and attainable achievement or accomplishment. It is not soft. A soft goal is one that is worded in such as way that there may be a question as to what exactly the goal statement means or when it is achieved. It may contain words such as better or improved that require further definition to be fully understood.

Measurable: The goal and progress toward it (in Objectives) can be measured. Ask: How will I measure progress? How will I know when I have achieved this goal? What will it look like when I achieve it?

Action-Oriented: Goals can be attained within established time frames by specific actions or steps (Objectives)

Relevant: The goal is consistent with other goals you have established. It fits your long- and short-term plans for your life. It contributes to an overall improvement in your status, functioning, and supports.

Time-Bound: There is a specific, reasonable date by which you will attain the goal.

Goal Statements Rubric

Component Does Not Meet Standard Meets Standard

Specific

Fuzzy, soft, intangible. May be overly subjective.

May describe feelings, emotions or sentiments that cannot be objectively observed by self or others.

Specifically described in terms of what, how well, how much, how many (or other measurable and tangible terms.)

The recipient and others (objective third parties) can objectively identify when the goal is attained.

• improved overall health;

• improved status (independence, housing, employment, education, legal status, other);

• improved (paid and natural) support networks that the client can use and rely on during difficult times or in crisis;

• improved engagement in medically necessary or preventative mental health and health care services; and

• reduced overall healthcare costs.

Goals and Objectives for Case Management Services

GoalsThe case manager helps the recipient identify goals and to transform intangible or negatively-stated (what I don't want) goals into goals that are positive, achievable and tangible. SMART goals are:

Specific: The goals statement describes a specifically measurable and attainable achievement or accomplishment. It is not soft. A soft goal is one that is worded in such as way that there may be a question as to what exactly the goal statement means or when it is achieved. It may contain words such as better or improved that require further definition to be fully understood.

Measurable: The goal and progress toward it (in Objectives) can be measured. Ask: How will I measure progress? How will I know when I have achieved this goal? What will it look like when I achieve it?

Action-Oriented: Goals can be attained within established time frames by specific actions or steps (Objectives)

Relevant: The goal is consistent with other goals you have established. It fits your long- and short-term plans for your life. It contributes to an overall improvement in your status, functioning, and supports.

Time-Bound: There is a specific, reasonable date by which you will attain the goal.

Goal Statements Rubric

Component Does Not Meet Standard Meets Standard

Specific

Fuzzy, soft, intangible. May be overly subjective.

May describe feelings, emotions or sentiments that cannot be objectively observed by self or others.

Specifically described in terms of what, how well, how much, how many (or other measurable and tangible terms.)

The recipient and others (objective third parties) can objectively identify when the goal is attained.

Measurable

One's self and others cannot ultimately determine specifically or objectively identified by the recipient and others (objective third parties) when achieved

(the recipient and others will not be able to answer yes or no, attained ornot.)

Can be specifically identified by self and others when achieved. Progress toward the goal can be measured in achievable, smaller steps.

Ultimately binary (the recipient and others can yes or no, attained or not.)

Action-Oriented

The goal may not be actionable or it may be too fuzzy, soft or intangible to describe specific actionable steps to attain it.

Describes a goal that can be broken down into specific, component, measurable and actionable step (Objectives) toward attainment.

Relevant

Relevance to current status and functioning are not clear.

Relevance to other goals and how this goal contributes to improve functioning and status are not clear.

Relates directly to improvements in functioning and/or status, or obtainment of supports and services that support other goals and improve status and functioning in this and other domains.

Time-Bound Lacks a specific date or timeline by which the goal will be attained.

Contains a specific date or timeline by whichthe goal will be attained.

Measurable

One's self and others cannot ultimately determine specifically or objectively identified by the recipient and others (objective third parties) when achieved

(the recipient and others will not be able to answer yes or no, attained ornot.)

Can be specifically identified by self and others when achieved. Progress toward the goal can be measured in achievable, smaller steps.

Ultimately binary (the recipient and others can yes or no, attained or not.)

Action-Oriented

The goal may not be actionable or it may be too fuzzy, soft or intangible to describe specific actionable steps to attain it.

Describes a goal that can be broken down into specific, component, measurable and actionable step (Objectives) toward attainment.

Relevant

Relevance to current status and functioning are not clear.

Relevance to other goals and how this goal contributes to improve functioning and status are not clear.

Relates directly to improvements in functioning and/or status, or obtainment of supports and services that support other goals and improve status and functioning in this and other domains.

Time-Bound Lacks a specific date or timeline by which the goal will be attained.

Contains a specific date or timeline by whichthe goal will be attained.

Objectives Objectives for Case Management are the smaller, measurable, specific, tangible and positive steps the recipient can take toward achieving his or her goals. Use the acronym STEPS to guide the process ofwriting objectives statements for Case Management services.

Smaller, Specific (describing exactly what will occur and when it will occur)

Tangible (can be measured within time frames and not soft, as for goals)

Elemental (representing the goal broken down into its consecutive component elements, which are incremental)

Positive (specifically measurable achievements that move you closer toward goal-attainment)

Steps (toward the goal with which they are associated)

Objectives Rubric

Component Does Not Meet Standard Meets Standard

Smaller, Specific

Are soft, fuzzy, intangible or unspecific. Are too large, encompassing more than one step or achievement. May contain “and.”

Describe exactly what will occur and when itwill occur. Are clearly achievable. Describe only one measurable achievement.

Tangible

Cannot be specifically measured within time frames. The recipient and others cannot ultimately identify (as for goals): achievedor not.

Can be measured within time frames. The recipient and others (objective third parties) can identify when the objective is achieved. Ultimately binary: achieved or not.

Elemental

However important, not directly related to the goal, or unclear as to relevance to the goal. Not representing steps that overcome barriers to the goal.

Directly related to the goal. Ordered, consecutive, incremental componentelements of, or steps toward, the goal itself.

Positive Not actionable. Passive: happens to the recipient, rather than as a result of actions that the recipient and/or case manager take.

Describe specifically measurable actionable steps or achievements that move the recipient closer to goal-attainment. Describe actions taken by the recipient and/or case manager.

Steps Do not represent steps that can be usedas a measurement of progress toward goal achievement. Not a checklist toward goal achievement.

Are the measurement of progress toward thegoal. Each objective achieved represents a step toward goal attainment. Can be used as a checklist by which progress toward goal attainment can be measured.

Objectives Objectives for Case Management are the smaller, measurable, specific, tangible and positive steps the recipient can take toward achieving his or her goals. Use the acronym STEPS to guide the process ofwriting objectives statements for Case Management services.

Smaller, Specific (describing exactly what will occur and when it will occur)

Tangible (can be measured within time frames and not soft, as for goals)

Elemental (representing the goal broken down into its consecutive component elements, which are incremental)

Positive (specifically measurable achievements that move you closer toward goal-attainment)

Steps (toward the goal with which they are associated)

Objectives Rubric

Component Does Not Meet Standard Meets Standard

Smaller, Specific

Are soft, fuzzy, intangible or unspecific. Are too large, encompassing more than one step or achievement. May contain “and.”

Describe exactly what will occur and when itwill occur. Are clearly achievable. Describe only one measurable achievement.

Tangible

Cannot be specifically measured within time frames. The recipient and others cannot ultimately identify (as for goals): achievedor not.

Can be measured within time frames. The recipient and others (objective third parties) can identify when the objective is achieved. Ultimately binary: achieved or not.

Elemental

However important, not directly related to the goal, or unclear as to relevance to the goal. Not representing steps that overcome barriers to the goal.

Directly related to the goal. Ordered, consecutive, incremental componentelements of, or steps toward, the goal itself.

Positive Not actionable. Passive: happens to the recipient, rather than as a result of actions that the recipient and/or case manager take.

Describe specifically measurable actionable steps or achievements that move the recipient closer to goal-attainment. Describe actions taken by the recipient and/or case manager.

Steps Do not represent steps that can be usedas a measurement of progress toward goal achievement. Not a checklist toward goal achievement.

Are the measurement of progress toward thegoal. Each objective achieved represents a step toward goal attainment. Can be used as a checklist by which progress toward goal attainment can be measured.

Case Management Documentation

Documenting the Four Core Service Components of AMH-TCM The diagram here illustrates the four core service components of AMH-TCM. What follows in the tablebelow is an explanation of how to document each. Progress Notes for Case management must describe one of these core services.

You may provide core services in a variety of ways, including face-to-face, over the phone with the recipient, or on behalf of the recipient in advocacy with others or while putting final touches on assessments and ICSPs after meeting with the recipient to conduct the assessment. As described in the Billing Guidelines, above, you should provide at least one core service in a face-to- face session monthly.

Core Component How to Document

Assessment

Assessment refers to all assessment required for Case Management services, including: • Review of the Diagnostic Assessment • Functional Assessment • LOCUS • Health Assessments and others requested by the insurer or other health

care and social services providers with whom you will advocate for services for the recipientAssessment should take place with the recipient as much as possible. Record this as Case Management – Face-to-Face contact when doing so. When completing work on assessments away from the recipient, this time is also billable as Case Management work. Document this time as Case Management – Assessment.

Planning

Planning includes develop of the recipient's Long-Term Goals and the Individual Community Support Plan. It may also include other planning activities done with the recipient for obtaining and maintaining health care and social services. Planning should take place with the recipient. Record this as Case Management – Face-to-Face contact when doing so. When completing final work on planning documents away from the recipient, this time is also billable as Case Management work. Documentthis time as Case Management – Assessment. Planning work documented as such (not done with the recipient) should be rare.

Referral and Linkage

Referral and linkage means identifying, referring the recipient to, and advocating on behalf of the recipient for necessary health care, residential, and social services. When done with the recipient, document this as Case Management – Face-to-Face contact. When done away from the recipient, whether over the phone or in-person with providers, document this as Case Management – Advocacy.

Monitoring and Coordination

Monitoring and coordination means monitoring the quality of necessary health care, residential, and social services. This might include meeting with the recipient to assess whether or not his or her needs are being met, review of documents (assessments, treatment or support plans, progress notes and reviews), meetings with providers, phone contacts to providers for advocating on behalf of the recipient, and following upwith providers regarding recipient needs or problems. When done with the recipient, document this as Case Management – Face-to-Face contact. When done away from the recipient, whether over the phone or in-person withproviders, document this as Case Management – Advocacy.

Case Management Documentation

Documenting the Four Core Service Components of AMH-TCM The diagram here illustrates the four core service components of AMH-TCM. What follows in the tablebelow is an explanation of how to document each. Progress Notes for Case management must describe one of these core services.

You may provide core services in a variety of ways, including face-to-face, over the phone with the recipient, or on behalf of the recipient in advocacy with others or while putting final touches on assessments and ICSPs after meeting with the recipient to conduct the assessment. As described in the Billing Guidelines, above, you should provide at least one core service in a face-to- face session monthly.

Core Component How to Document

Assessment

Assessment refers to all assessment required for Case Management services, including: • Review of the Diagnostic Assessment • Functional Assessment • LOCUS • Health Assessments and others requested by the insurer or other health

care and social services providers with whom you will advocate for services for the recipientAssessment should take place with the recipient as much as possible. Record this as Case Management – Face-to-Face contact when doing so. When completing work on assessments away from the recipient, this time is also billable as Case Management work. Document this time as Case Management – Assessment.

Planning

Planning includes develop of the recipient's Long-Term Goals and the Individual Community Support Plan. It may also include other planning activities done with the recipient for obtaining and maintaining health care and social services. Planning should take place with the recipient. Record this as Case Management – Face-to-Face contact when doing so. When completing final work on planning documents away from the recipient, this time is also billable as Case Management work. Documentthis time as Case Management – Assessment. Planning work documented as such (not done with the recipient) should be rare.

Referral and Linkage

Referral and linkage means identifying, referring the recipient to, and advocating on behalf of the recipient for necessary health care, residential, and social services. When done with the recipient, document this as Case Management – Face-to-Face contact. When done away from the recipient, whether over the phone or in-person with providers, document this as Case Management – Advocacy.

Monitoring and Coordination

Monitoring and coordination means monitoring the quality of necessary health care, residential, and social services. This might include meeting with the recipient to assess whether or not his or her needs are being met, review of documents (assessments, treatment or support plans, progress notes and reviews), meetings with providers, phone contacts to providers for advocating on behalf of the recipient, and following upwith providers regarding recipient needs or problems. When done with the recipient, document this as Case Management – Face-to-Face contact. When done away from the recipient, whether over the phone or in-person withproviders, document this as Case Management – Advocacy.

AMH-TCM Progress Notes Case Management Progress notes contain the following elements:

Upon selecting the Case Management service type, you are prompted to confirm or update the recipient's current residence and recent facility placements. DO NOT ignore these questions.

• Has the client's permanent residence changed since your last visit?

• Has the client been admitted to and/or stayed overnight in any of the following facilities sinceyour last visit?

- Acute Care Hospital - Overnight Detoxification Center - Chemical Dependency Treatment - Intensive Residential Treatment - Crisis Stabilization - Skilled Nursing Facility (Nursing Home) - Physical Rehabilitation Center/Facility - Jail/Prison

Element Guidance

Risk Assessment: Identify any current risks identified during the session and explain specific actionsyou have taken to respond to, reduce or eliminate these risks and ensure the safety of the client and others. If no risks are identified, check the box indicatingthis.

Observations: General, targeted observations of the recipient's presentation and status. Make these observations targeted and relevant. (See guidance below.)

Intervention: What did you, the Case Manager do during this visit to help the recipient with current needs, goals, objectives and outcomes?

Response: What was the client's response to and participation in the intervention?

Plan: When will you meet next (a specific appointment date and time are strongly recommended)?

What will you do during this visit?

What steps will you take to help the client between visits (advocacy, referrals, follow-up calls, etc.)?

What steps will the recipient take in between sessions based on the work you have done in this one?

AMH-TCM Progress Notes Case Management Progress notes contain the following elements:

Upon selecting the Case Management service type, you are prompted to confirm or update the recipient's current residence and recent facility placements. DO NOT ignore these questions.

• Has the client's permanent residence changed since your last visit?

• Has the client been admitted to and/or stayed overnight in any of the following facilities sinceyour last visit?

- Acute Care Hospital - Overnight Detoxification Center - Chemical Dependency Treatment - Intensive Residential Treatment - Crisis Stabilization - Skilled Nursing Facility (Nursing Home) - Physical Rehabilitation Center/Facility - Jail/Prison

Element Guidance

Risk Assessment: Identify any current risks identified during the session and explain specific actionsyou have taken to respond to, reduce or eliminate these risks and ensure the safety of the client and others. If no risks are identified, check the box indicatingthis.

Observations: General, targeted observations of the recipient's presentation and status. Make these observations targeted and relevant. (See guidance below.)

Intervention: What did you, the Case Manager do during this visit to help the recipient with current needs, goals, objectives and outcomes?

Response: What was the client's response to and participation in the intervention?

Plan: When will you meet next (a specific appointment date and time are strongly recommended)?

What will you do during this visit?

What steps will you take to help the client between visits (advocacy, referrals, follow-up calls, etc.)?

What steps will the recipient take in between sessions based on the work you have done in this one?

Objective DocumentationThe easiest way to understand what is objective is this: document only what you can detect with your senses (see, hear, smell,taste, feel) or what the recipient tells you. Do not draw conclusions, no matter how firmly you believe you are correct. Allow the reader to interpret what you observed.

Always AvoidDiagnostic terms (practitioners) : depressed, anxious, etc. This is out of scope of practice for a practitioner.

Emotions: angry, upset, worried, happy, sad, etc. You cannot detect emotions with your senses, and you could be wrong!

Judgment, conclusions, your opinion : appropriate/inappropriate, cooperative/uncooperative, etc. Judgement is not person-centered, and reflects only your opinion. Conclusions are what you believe, not what you observed.

ExamplesWhile these are just a few examples, please use them to check your own documentation, and to generalize to other observations you might document. Or, ask the recipient and write what he or she reports: “Jim said he was/felt...”

DO NOT WRITE:Diagnoses, Emotions, Judgments, Conclusions

INSTEAD WRITE:What you detect with your senses and should document

BECAUSE:There may be alternative possible explanations

Had been drinking Smelled of alcohol, slurred words, stumbled... Had recently used some mouthwashes, hand sanitizers, or medications. Has a health condition impacting balance or coordination.

Dressed inappropriately Dirty, torn, worn, too large/small, highly revealing, or clothing with offensive messages (example a t-shirt: whatdid it say?), etc...

These are the only clothes the person has,personal preference

Poorly groomed Had not shaved, combed hair, dirty hands, face, hair, had a strong unpleasant body, foot odor, etc....

Preference, came from work, homeless...

Happy Laughed, smiled... Anxious, nervous, confused, amused, under the influence

Sad, upset... Cried, frowned... Happy, scared, confused

Nervous, manic, anxious... Spoke rapidly, paced... Excited, this is normal for the person

Yelled Spoke loudly Hard of hearing, this is normal for the person

Angry, upset... Spoke loudly, clenched fists, pounded fists, stomped feet, cursed...

Feels passionately about the subject

Uncooperative Did not answer questions, walked away... Did not hear you, was nervous or frightened

Argued, argumentative, combative...

Said... (“quote statement of disagreement”) Learns by, prefers a dialectic method

Depressed Cried, frowned, spoke very little, softly, very little... Shy, frightened, nervous

Emotional Laughed, cried, spoke loudly, softly, very little... Shy, frightened, nervous, or normal for the person

Refused Declined recipient's have a right to refuse. “Declined”is more respectful.

Demanded Asked for “Demanded” is judgmental. “Asked for” means the same thing without judgment.

Lied Describe objectively what the recipient said, quote the recipient. Objectively identify conflicts with the facts, if known.

The recipient feels, or is fearful of, judgment, blame, ridicule, or pressure.

Manipulated, manipulative Describe objectively what the recipient said, quote the recipient. Do not make a conclusion about intent.

The recipient is using a skill everyone uses to get needs met. How you may feel aboutit (manipulated) is not relevant.

Objective DocumentationThe easiest way to understand what is objective is this: document only what you can detect with your senses (see, hear, smell,taste, feel) or what the recipient tells you. Do not draw conclusions, no matter how firmly you believe you are correct. Allow the reader to interpret what you observed.

Always AvoidDiagnostic terms (practitioners) : depressed, anxious, etc. This is out of scope of practice for a practitioner.

Emotions: angry, upset, worried, happy, sad, etc. You cannot detect emotions with your senses, and you could be wrong!

Judgment, conclusions, your opinion : appropriate/inappropriate, cooperative/uncooperative, etc. Judgement is not person-centered, and reflects only your opinion. Conclusions are what you believe, not what you observed.

ExamplesWhile these are just a few examples, please use them to check your own documentation, and to generalize to other observations you might document. Or, ask the recipient and write what he or she reports: “Jim said he was/felt...”

DO NOT WRITE:Diagnoses, Emotions, Judgments, Conclusions

INSTEAD WRITE:What you detect with your senses and should document

BECAUSE:There may be alternative possible explanations

Had been drinking Smelled of alcohol, slurred words, stumbled... Had recently used some mouthwashes, hand sanitizers, or medications. Has a health condition impacting balance or coordination.

Dressed inappropriately Dirty, torn, worn, too large/small, highly revealing, or clothing with offensive messages (example a t-shirt: whatdid it say?), etc...

These are the only clothes the person has,personal preference

Poorly groomed Had not shaved, combed hair, dirty hands, face, hair, had a strong unpleasant body, foot odor, etc....

Preference, came from work, homeless...

Happy Laughed, smiled... Anxious, nervous, confused, amused, under the influence

Sad, upset... Cried, frowned... Happy, scared, confused

Nervous, manic, anxious... Spoke rapidly, paced... Excited, this is normal for the person

Yelled Spoke loudly Hard of hearing, this is normal for the person

Angry, upset... Spoke loudly, clenched fists, pounded fists, stomped feet, cursed...

Feels passionately about the subject

Uncooperative Did not answer questions, walked away... Did not hear you, was nervous or frightened

Argued, argumentative, combative...

Said... (“quote statement of disagreement”) Learns by, prefers a dialectic method

Depressed Cried, frowned, spoke very little, softly, very little... Shy, frightened, nervous

Emotional Laughed, cried, spoke loudly, softly, very little... Shy, frightened, nervous, or normal for the person

Refused Declined recipient's have a right to refuse. “Declined”is more respectful.

Demanded Asked for “Demanded” is judgmental. “Asked for” means the same thing without judgment.

Lied Describe objectively what the recipient said, quote the recipient. Objectively identify conflicts with the facts, if known.

The recipient feels, or is fearful of, judgment, blame, ridicule, or pressure.

Manipulated, manipulative Describe objectively what the recipient said, quote the recipient. Do not make a conclusion about intent.

The recipient is using a skill everyone uses to get needs met. How you may feel aboutit (manipulated) is not relevant.

Using “Appeared,” or “Seemed”

Using the words “appeared,” or “seemed” in front of a non-objective word does not make it objective. If you are writing “appeared” or “seemed” it must also be followed by an objective word. Examples:

Incorrect: “She appeared to be upset when I arrived, but seemed to recover when I greeted her.”

Correct: “Her eyes looked wet and her cheeks appeared red, but she seemed to smile when I said 'hello.'”

Pseudo-Objectivity

Many academic programs, and agencies, teach a style of documentation in which the provider never uses pronouns to refer to him or herself (I, me, my) rather by job title or service (TCM, ARMHS), refers to the person as “recipient,” and even often references third party professionals by job title or service (TCM, ARMHS, Therapist).This style of documentation is purported, by those who promote it, to be more professional, creating objective professional distance. In reality, it does not.

This style of documentation is strongly discouraged at Accend. Do not use it! We discourage this style primarily because it is often imprecise. It fails to provide the reader with sufficient information. Look at this example:

Incorrect and imprecise: “TCM met with client and ARMHS to review client's progress. ARMHS will update the Treatment Plan with the goals we discussed.”

Why: “TCM” could be yourself, or another Case Management provider. We want to know who. You can use the recipient's name (it is already right at the top of the note). “ARMHS” could be the recipient's ARMHS practitioner, associate, worker, peer specialist, or clinical supervisor, or combination thereof. “Client” in the second usage could be the client who is the subject of the note, or another person, perhaps the client's child, who is also a client of our agency.

Correct, acceptable, and precise: “I met with Joe and his ARMHS Practitioner, Sally Smith, and Clinical Supervisor, John Adams, to review his progress. Sally will update the treatment plan with the goals we discussed.”

Active versus Passive Voice Using the active voice when possible requires fewer words and produces generally stronger, clearer communication with fewer words. Look for forms of the verb to be for warning signs of passive voice, as in the following examples:

Passive Voice Active Voice

The assessment was completed by the client and me. We completed the assessment.

The redetermination paperwork will be completed by me and will be submitted by the end of the week.

I will complete and submit the redeterminationpaperwork by Friday.

Avoid LingoDo not use lingo to describe your intervention. Describe what you actually did. Lingo is imprecise and unclear. Examples:

-Do not write “monitored ARMHS.” What does that mean? Write: “I asked her if she was seeing her ARMHS provider and how it was going... Client response.”

-Do not write “linked client to...” a service/place. What does this mean? You called the provider? Drove him there? Introduced him to someone?

Using “Appeared,” or “Seemed”

Using the words “appeared,” or “seemed” in front of a non-objective word does not make it objective. If you are writing “appeared” or “seemed” it must also be followed by an objective word. Examples:

Incorrect: “She appeared to be upset when I arrived, but seemed to recover when I greeted her.”

Correct: “Her eyes looked wet and her cheeks appeared red, but she seemed to smile when I said 'hello.'”

Pseudo-Objectivity

Many academic programs, and agencies, teach a style of documentation in which the provider never uses pronouns to refer to him or herself (I, me, my) rather by job title or service (TCM, ARMHS), refers to the person as “recipient,” and even often references third party professionals by job title or service (TCM, ARMHS, Therapist).This style of documentation is purported, by those who promote it, to be more professional, creating objective professional distance. In reality, it does not.

This style of documentation is strongly discouraged at Accend. Do not use it! We discourage this style primarily because it is often imprecise. It fails to provide the reader with sufficient information. Look at this example:

Incorrect and imprecise: “TCM met with client and ARMHS to review client's progress. ARMHS will update the Treatment Plan with the goals we discussed.”

Why: “TCM” could be yourself, or another Case Management provider. We want to know who. You can use the recipient's name (it is already right at the top of the note). “ARMHS” could be the recipient's ARMHS practitioner, associate, worker, peer specialist, or clinical supervisor, or combination thereof. “Client” in the second usage could be the client who is the subject of the note, or another person, perhaps the client's child, who is also a client of our agency.

Correct, acceptable, and precise: “I met with Joe and his ARMHS Practitioner, Sally Smith, and Clinical Supervisor, John Adams, to review his progress. Sally will update the treatment plan with the goals we discussed.”

Active versus Passive Voice Using the active voice when possible requires fewer words and produces generally stronger, clearer communication with fewer words. Look for forms of the verb to be for warning signs of passive voice, as in the following examples:

Passive Voice Active Voice

The assessment was completed by the client and me. We completed the assessment.

The redetermination paperwork will be completed by me and will be submitted by the end of the week.

I will complete and submit the redeterminationpaperwork by Friday.

Avoid LingoDo not use lingo to describe your intervention. Describe what you actually did. Lingo is imprecise and unclear. Examples:

-Do not write “monitored ARMHS.” What does that mean? Write: “I asked her if she was seeing her ARMHS provider and how it was going... Client response.”

-Do not write “linked client to...” a service/place. What does this mean? You called the provider? Drove him there? Introduced him to someone?

AMH-TCM Progress Notes Rubric Use this Rubric to assess the quality of your AMH-TCM Progress Notes:

Unacceptable Acceptable

Concise Notes are excessively wordy.

May contain excessive passive voice.*

Notes describe concisely, but completely, the activities, observations and content of the session.

Writing in the present tense and active voice* eliminates excessive verbiage.

ObjectiveProgress Notes contain subjective observations, may use words that diagnose, or contain opinion or judgements of the Case Manager.

Progress Notes describe the recipient and othersonly with objective observations or by reporting what the recipient or others said.

Relevant Notes contain extraneous, distracting orunnecessary detail.

Notes describe core services, and include only targeted, relevant observations necessary to inform the reader as relates to the services provided, the recipient's current status and functioning, and needs/plans for future services.

Elemental Notes do not describe one of the CoreCase Management services. They may describe describe custodial services (relating to, providing, or being protective care or services for basic needs, personal care, transportation, orother non-core services) rather than referral, brokering, monitoring necessaryservices on behalf of the recipient.

Notes are imprecise because of lingo (referred, linked, monitored, etc.)

Notes describe Core Case Management services.

As with objectives, Case Management Progress Notes demonstrate the elemental steps necessary to help move the recipient toward goal achievement.

They describe work on objectives in the plan.

They illustrate services provided that promote maximum recipient independence.

The notes describe the intervention in detail.

AMH-TCM Progress Notes Rubric Use this Rubric to assess the quality of your AMH-TCM Progress Notes:

Unacceptable Acceptable

Concise Notes are excessively wordy.

May contain excessive passive voice.*

Notes describe concisely, but completely, the activities, observations and content of the session.

Writing in the present tense and active voice* eliminates excessive verbiage.

ObjectiveProgress Notes contain subjective observations, may use words that diagnose, or contain opinion or judgements of the Case Manager.

Progress Notes describe the recipient and othersonly with objective observations or by reporting what the recipient or others said.

Relevant Notes contain extraneous, distracting orunnecessary detail.

Notes describe core services, and include only targeted, relevant observations necessary to inform the reader as relates to the services provided, the recipient's current status and functioning, and needs/plans for future services.

Elemental Notes do not describe one of the CoreCase Management services. They may describe describe custodial services (relating to, providing, or being protective care or services for basic needs, personal care, transportation, orother non-core services) rather than referral, brokering, monitoring necessaryservices on behalf of the recipient.

Notes are imprecise because of lingo (referred, linked, monitored, etc.)

Notes describe Core Case Management services.

As with objectives, Case Management Progress Notes demonstrate the elemental steps necessary to help move the recipient toward goal achievement.

They describe work on objectives in the plan.

They illustrate services provided that promote maximum recipient independence.

The notes describe the intervention in detail.

Guidelines for Documenting Special Circumstances

Eligibility review: (Assessment)

The first steps in the core case management Assessment function is review of assessments to determine eligibility for case management services. Document this as Case Management Eligibility Screening.

Initial contacts: (Assessment)

You must see the recipient for at least one initial face-to-face meeting during the first month we bill for case management services. Once a recipient is found eligible, the first face-to-face meeting is the admission date. Document all other efforts to contact he recipient as Contact and Scheduling. Document supports and service provided prior to the determination of eligibility, or to an uninsured recipient as Outreach.

Client Cancellationsby telephone:

Document recipient-cancellations by using the CCN service type.

However, if If you have made efforts to see the recipient by contacting him or her by phone to make, cancel, or re-arrange the appointment, document this as Case Management- Contact and Scheduling.

If during the call, you conduct a brief needs assessment, and the reason for the cancellation is that the recipient has indicated that he or she does not need help atthis time, document this as Case Management – Phone Contact.

Client Cancellationsupon arrival:

If you have seen the recipient, but he or she shortens the appointment or declines services upon your arrival, document this as Case Management- Face-to-Face time and include travel. (You have seen the recipient, who has indicated that he or she does not need help at this time.)

No-shows Document these as cancellations.

Assessment and Service Planning:

Conduct these core activities as much as possible with the recipient. Putting final touches on documents and preparing them for release to extended support team meetings is Case Management- Advocacy.

Advocacy and intervention with others:

When making contacts on behalf of the recipient, writing correspondence, telephoningand other Document these core components (Referral and Linkage, Monitoring and Coordination) as Case Management- Advocacy.)

When making these contacts with the recipient, document them as Case Management- Face-to-Face Contact.

Case management travel time:

Document Case Management Travel Time only when traveling to a billable service (from the office or from a previous recipient) or when returning to the office from a billable recipient service. When traveling directly to your first recipient of the day, or home from your last, document travel to/from home or the office, whichever is shorter.

Travel between departments:

If you are assigned to recipients in two different departments (county offices) and work in both departments on the same day, do not bill travel between departments. Bill only time spent traveling from the local office to the recipient in that department.

Guidelines for Documenting Special Circumstances

Eligibility review: (Assessment)

The first steps in the core case management Assessment function is review of assessments to determine eligibility for case management services. Document this as Case Management Eligibility Screening.

Initial contacts: (Assessment)

You must see the recipient for at least one initial face-to-face meeting during the first month we bill for case management services. Once a recipient is found eligible, the first face-to-face meeting is the admission date. Document all other efforts to contact he recipient as Contact and Scheduling. Document supports and service provided prior to the determination of eligibility, or to an uninsured recipient as Outreach.

Client Cancellationsby telephone:

Document recipient-cancellations by using the CCN service type.

However, if If you have made efforts to see the recipient by contacting him or her by phone to make, cancel, or re-arrange the appointment, document this as Case Management- Contact and Scheduling.

If during the call, you conduct a brief needs assessment, and the reason for the cancellation is that the recipient has indicated that he or she does not need help atthis time, document this as Case Management – Phone Contact.

Client Cancellationsupon arrival:

If you have seen the recipient, but he or she shortens the appointment or declines services upon your arrival, document this as Case Management- Face-to-Face time and include travel. (You have seen the recipient, who has indicated that he or she does not need help at this time.)

No-shows Document these as cancellations.

Assessment and Service Planning:

Conduct these core activities as much as possible with the recipient. Putting final touches on documents and preparing them for release to extended support team meetings is Case Management- Advocacy.

Advocacy and intervention with others:

When making contacts on behalf of the recipient, writing correspondence, telephoningand other Document these core components (Referral and Linkage, Monitoring and Coordination) as Case Management- Advocacy.)

When making these contacts with the recipient, document them as Case Management- Face-to-Face Contact.

Case management travel time:

Document Case Management Travel Time only when traveling to a billable service (from the office or from a previous recipient) or when returning to the office from a billable recipient service. When traveling directly to your first recipient of the day, or home from your last, document travel to/from home or the office, whichever is shorter.

Travel between departments:

If you are assigned to recipients in two different departments (county offices) and work in both departments on the same day, do not bill travel between departments. Bill only time spent traveling from the local office to the recipient in that department.

Additional Links For Further Information ▷MHCP Manual – Adult Mental Health-Targeted Case Management ▷MS 245.462 subd. 4 Case Manager Qualifications▷MS 245.462 Definitions▷MS 256B.0625 , subd. 20 Mental Health Case Management▷Minnesota Rules 9505.0322 Mental Health Case Management Services

Additional Links For Further Information ▷MHCP Manual – Adult Mental Health-Targeted Case Management ▷MS 245.462 subd. 4 Case Manager Qualifications▷MS 245.462 Definitions▷MS 256B.0625 , subd. 20 Mental Health Case Management▷Minnesota Rules 9505.0322 Mental Health Case Management Services

Addendum: Client Grievances or Complaints

Medica

Complaint and Appeal ProcedureWhen members have a complaint or disagree with how their plan is administered, they can contact Customer Service to discuss their options. Members can file complaints and request a review of the initial decision. Members have a minimum of one level of review internally and may have external appeal options as well. Some complaints and appeal need to be requested in writing or over the phone. Please refer members to the Customer Service phone number on the back of their identification card to discuss the process for their plan. Medica also has a process in place for resolving expedited appeals.

Members have the right to designate a representative to act on their behalf during the appeal resolution process. A provider may initiate an appeal on behalf of a member with a member’s written permission. Members must sign a Release of Information form acknowledging that the representative has their permission to review confidential information pertinent to their appeal.

Providers may contact the Clinical Appeals Department directly to initiate an appeal request on behalfof a member, except for members covered under Medica’s Medicare products. Any new information about a previously denied service will assist in an accurate and appropriate benefit determination. Written requests for appeal initiation should be directed to:

For Medica members with group/policy #IFB, send appeals to:

MedicaClinical Appeals DepartmentMail Route CW295PO Box 9310Minneapolis, MN 55440-9310Fax Number (952) 992-2836Phone number 1(855) 235-0511

For all other Medica members, send appeals to:

Medica Clinical Appeals Department Mail Route CP420 PO Box 9310 Minneapolis, MN 55440-9310 Fax: (952) 992-8403 Phone number 1 (800) 458-5512

Issues regarding coding or reimbursement need to be directed to the Provider Service Center at (800)458-5512.

Addendum: Client Grievances or Complaints

Medica

Complaint and Appeal ProcedureWhen members have a complaint or disagree with how their plan is administered, they can contact Customer Service to discuss their options. Members can file complaints and request a review of the initial decision. Members have a minimum of one level of review internally and may have external appeal options as well. Some complaints and appeal need to be requested in writing or over the phone. Please refer members to the Customer Service phone number on the back of their identification card to discuss the process for their plan. Medica also has a process in place for resolving expedited appeals.

Members have the right to designate a representative to act on their behalf during the appeal resolution process. A provider may initiate an appeal on behalf of a member with a member’s written permission. Members must sign a Release of Information form acknowledging that the representative has their permission to review confidential information pertinent to their appeal.

Providers may contact the Clinical Appeals Department directly to initiate an appeal request on behalfof a member, except for members covered under Medica’s Medicare products. Any new information about a previously denied service will assist in an accurate and appropriate benefit determination. Written requests for appeal initiation should be directed to:

For Medica members with group/policy #IFB, send appeals to:

MedicaClinical Appeals DepartmentMail Route CW295PO Box 9310Minneapolis, MN 55440-9310Fax Number (952) 992-2836Phone number 1(855) 235-0511

For all other Medica members, send appeals to:

Medica Clinical Appeals Department Mail Route CP420 PO Box 9310 Minneapolis, MN 55440-9310 Fax: (952) 992-8403 Phone number 1 (800) 458-5512

Issues regarding coding or reimbursement need to be directed to the Provider Service Center at (800)458-5512.

Blue Plus (Blue Cross Blue Shield of Minnesota)Please refer member complaints and grievances for the following Medicare and/or Medicaid products to the phone number listed below:

Blue Advantage PMAP and MnCare (Under 65 Medicaid products)Member Services 1-800-711-9862

Blue Advantage MSC+ (Over 65 Medicaid product)Member Services 1-800-711-9862

SecureBlue MSHO (Over 65 Medicare/Medicaid product)Member Services 1-888-740-6013

If a member would like to file a complaint or grievance about their TCM agency services, they may call the appropriate number on the back of their card (also listed above).

Complaints subject to Blue Plus’s grievance process may include, but are not limited to:

• Concerns regarding services received from Blue Cross Member Services – hold times, calling several times on same issue, not being called back, not getting an adequate response to issue

• BlueRide transportation concerns• Disagree with appeals process and or decision made by the Health Plan• Health Plan does not make a decision on a filed appeal within the required time frame • Notices and other written materials are hard to understand • Problems with the quality of the medical care or services received, including quality of care

during a hospital stay • Concerns regarding wait time on the phone, in the waiting room, or in the exam room at a

provider’s office• Difficulty in getting appointments when needed• Unprofessional behavior by doctors, nurses, receptionists, or other staff• Cleanliness or condition of doctor offices, clinics or hospitals

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

BLUE PLUS GRIEVANCESFor those enrolled in PMAP/MnCARE, MSHO, MSC+ public programs

Blue Plus (Blue Cross Blue Shield of Minnesota)Please refer member complaints and grievances for the following Medicare and/or Medicaid products to the phone number listed below:

Blue Advantage PMAP and MnCare (Under 65 Medicaid products)Member Services 1-800-711-9862

Blue Advantage MSC+ (Over 65 Medicaid product)Member Services 1-800-711-9862

SecureBlue MSHO (Over 65 Medicare/Medicaid product)Member Services 1-888-740-6013

If a member would like to file a complaint or grievance about their TCM agency services, they may call the appropriate number on the back of their card (also listed above).

Complaints subject to Blue Plus’s grievance process may include, but are not limited to:

• Concerns regarding services received from Blue Cross Member Services – hold times, calling several times on same issue, not being called back, not getting an adequate response to issue

• BlueRide transportation concerns• Disagree with appeals process and or decision made by the Health Plan• Health Plan does not make a decision on a filed appeal within the required time frame • Notices and other written materials are hard to understand • Problems with the quality of the medical care or services received, including quality of care

during a hospital stay • Concerns regarding wait time on the phone, in the waiting room, or in the exam room at a

provider’s office• Difficulty in getting appointments when needed• Unprofessional behavior by doctors, nurses, receptionists, or other staff• Cleanliness or condition of doctor offices, clinics or hospitals

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

BLUE PLUS GRIEVANCESFor those enrolled in PMAP/MnCARE, MSHO, MSC+ public programs

UCareMember Appeals & Grievances

M EMBER R IGHTS AND R ESPONSIBILITIES

UCare takes member rights and responsibilities seriously. Members can access these rights and responsibilities in their Evidence of Coverage or Member Contract. UCare recommends that providers be familiar with the Member Rights and Responsibilities and has included them here for your reference.

Member Rights and Responsibilities

As a UCare member of this plan, you have the right to:

• ! Available and accessible services including emergency services, as defined in your Contract, 24 hours a day and seven days a week;

• ! Be informed of health problems, and to receive information regarding medically necessary treatment options and risks that is sufficient to assure informed choice, regardless of cost or benefit coverage;

• ! Refuse treatment, and the right to privacy of medical and financial records maintained by UCare and its health care providers, in accordance with existing law;

• ! Make a grievance or appeal a coverage decision, and the right to initiate a legal proceedingwhen experiencing a problem with UCare or its health care providers. (See the Appeals and Grievances section for more information on your rights);

• ! Receive information about UCare, its services, its practitioners and providers, and your rights and responsibilities;

• ! Be treated with respect and recognition of your dignity and your right to privacy;

• ! Participate with your providers in making health care decisions; and

• ! Make recommendations regarding the organization’s member rights and responsibilities policy.

As a UCare member of this plan, you have the responsibility to:

• ! Supply information (to the extent possible) that the organization and its providers need in order to provide care;

• ! Follow plans and instructions for care that you have agreed to with your providers to sustainand manage your health;

• ! Understand your health needs and problems, and participate in developing mutually agreed- upon treatment goals to the degree possible; and

• ! Pay copayments at the time of service and to promptly pay deductibles, coinsurance and, if applicable, additional charges for non-covered services.

UCareMember Appeals & Grievances

M EMBER R IGHTS AND R ESPONSIBILITIES

UCare takes member rights and responsibilities seriously. Members can access these rights and responsibilities in their Evidence of Coverage or Member Contract. UCare recommends that providers be familiar with the Member Rights and Responsibilities and has included them here for your reference.

Member Rights and Responsibilities

As a UCare member of this plan, you have the right to:

• ! Available and accessible services including emergency services, as defined in your Contract, 24 hours a day and seven days a week;

• ! Be informed of health problems, and to receive information regarding medically necessary treatment options and risks that is sufficient to assure informed choice, regardless of cost or benefit coverage;

• ! Refuse treatment, and the right to privacy of medical and financial records maintained by UCare and its health care providers, in accordance with existing law;

• ! Make a grievance or appeal a coverage decision, and the right to initiate a legal proceedingwhen experiencing a problem with UCare or its health care providers. (See the Appeals and Grievances section for more information on your rights);

• ! Receive information about UCare, its services, its practitioners and providers, and your rights and responsibilities;

• ! Be treated with respect and recognition of your dignity and your right to privacy;

• ! Participate with your providers in making health care decisions; and

• ! Make recommendations regarding the organization’s member rights and responsibilities policy.

As a UCare member of this plan, you have the responsibility to:

• ! Supply information (to the extent possible) that the organization and its providers need in order to provide care;

• ! Follow plans and instructions for care that you have agreed to with your providers to sustainand manage your health;

• ! Understand your health needs and problems, and participate in developing mutually agreed- upon treatment goals to the degree possible; and

• ! Pay copayments at the time of service and to promptly pay deductibles, coinsurance and, if applicable, additional charges for non-covered services.

MEMBER APPEAL AND GRIEVANCE PROCESS | UCARE FOR SENIORS AND

ESSENTIACARE

See also: Evidence of Coverage and Medicare Managed Care Manual, Chapter 13: Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals.

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UCare Provider Manual: GrievancesDefinitions & Overview Grievance: Any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which UCare provides health care services, regardless of whether any remedial action can be taken.

Grievances do not involve problems related to coverage or payment for medical care, problems about being discharged from the hospital too soon, and problems about coverage for skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation services ending too soon.

Examples of grievances:

• ! Problems with the quality of the medical care, including quality of care during a hospital stay.

• ! Problems with Customer Services.

• ! Problems with wait time on the phone, in the waiting room, in a clinic/hospital or in the exam

room.

• ! Problems with getting appointments, or having to wait a long time for an appointment.

• ! Disrespectful or rude behavior by doctors, nurses, receptionists or other staff.

• ! Cleanliness or condition of doctor’s offices, clinics, nursing facilities or hospitals.

• ! Difficult-to-understand notices and other written materials.

• ! Failure to provide required notices.

• ! Discrimination.

Who can file:

A member or their representative.

Timeline for filing:

Within 60 days of the date of the incident that precipitated the grievance. The filing timeline may be extended if there is good cause for the delay.

How to file:

By calling UCare Customer Services or submitting a written grievance to Member Appeals and Grievances.

Required Resolution Timeframe and How the Resolution is Communicated to the Member:

MEMBER APPEAL AND GRIEVANCE PROCESS | UCARE FOR SENIORS AND

ESSENTIACARE

See also: Evidence of Coverage and Medicare Managed Care Manual, Chapter 13: Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals.

13-1

UCare Provider Manual: GrievancesDefinitions & Overview Grievance: Any complaint or dispute, other than one involving an organization determination, expressing dissatisfaction with the manner in which UCare provides health care services, regardless of whether any remedial action can be taken.

Grievances do not involve problems related to coverage or payment for medical care, problems about being discharged from the hospital too soon, and problems about coverage for skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation services ending too soon.

Examples of grievances:

• ! Problems with the quality of the medical care, including quality of care during a hospital stay.

• ! Problems with Customer Services.

• ! Problems with wait time on the phone, in the waiting room, in a clinic/hospital or in the exam

room.

• ! Problems with getting appointments, or having to wait a long time for an appointment.

• ! Disrespectful or rude behavior by doctors, nurses, receptionists or other staff.

• ! Cleanliness or condition of doctor’s offices, clinics, nursing facilities or hospitals.

• ! Difficult-to-understand notices and other written materials.

• ! Failure to provide required notices.

• ! Discrimination.

Who can file:

A member or their representative.

Timeline for filing:

Within 60 days of the date of the incident that precipitated the grievance. The filing timeline may be extended if there is good cause for the delay.

How to file:

By calling UCare Customer Services or submitting a written grievance to Member Appeals and Grievances.

Required Resolution Timeframe and How the Resolution is Communicated to the Member:

Oral Grievances

• ! Oral grievances are investigated and the findings or outcome are verbally communicated to the member within 30 calendar days from receipt of the grievance. A member can request a written response.

• ! The timeframe for resolving an oral grievance can be extended by up to an additional 14 calendar days if the member requests the extension or if UCare justifies a need for additional information and the delay is in the member’s best interest. If UCare extends the deadline, the member is immediately notified verbally and in writing of the reason(s) for the delay.

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! If the member does not agree or is dissatisfied with the response, the member can file a written grievance.

Written Grievances

• ! Written grievances are investigated and the findings or decision are communicated to the member in a letter within 30 calendar days from receipt of the grievance.

• ! An acknowledgment letter is sent to the member within ten (10) calendar days after receipt of the written grievance.

• ! The timeframe for resolving a written grievance can be extended by up to an additional 14 calendar days if the member requests the extension or if UCare justifies a need for additional information and the delay is in the member’s best interest. If UCare extends the deadline, the member is immediately notified verbally and in writing of the reason(s) for the delay.

An expedited grievance is a member’s complaint that UCare or one of its delegated entities refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. UCare must resolve these grievances within 24 hours of receipt.

Quality of Care Grievances

A quality of care complaint may be filed through UCare’s grievance process (See Quality of Care Review Process section in this chapter) and/or a Quality Improvement Organization (QIO).

If UCare receives a grievance about potential quality of care issues, a letter is sent to the member or representative with a summary of the issues and an explanation of the confidential peer review process. The letter also includes information on how to file a quality of care grievance with the QIO.

Quality Improvement Organization (QIO): An organization comprised of practicing doctors and other health care experts under contract to the federal government to monitor and improvethe care given to Medicare members. QIOs review complaints raised by members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans and ambulatory surgical centers. A QIO determines whether the quality of services meetsprofessionally recognized standards of health care, including whether appropriate health care services have been provided and whether services have been provided in appropriate settings.

The member or their representative has the right to file a quality of care grievance with the QIOin the state where they reside.

Quality of care grievances filed with the QIO must be made in writing.

Oral Grievances

• ! Oral grievances are investigated and the findings or outcome are verbally communicated to the member within 30 calendar days from receipt of the grievance. A member can request a written response.

• ! The timeframe for resolving an oral grievance can be extended by up to an additional 14 calendar days if the member requests the extension or if UCare justifies a need for additional information and the delay is in the member’s best interest. If UCare extends the deadline, the member is immediately notified verbally and in writing of the reason(s) for the delay.

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! If the member does not agree or is dissatisfied with the response, the member can file a written grievance.

Written Grievances

• ! Written grievances are investigated and the findings or decision are communicated to the member in a letter within 30 calendar days from receipt of the grievance.

• ! An acknowledgment letter is sent to the member within ten (10) calendar days after receipt of the written grievance.

• ! The timeframe for resolving a written grievance can be extended by up to an additional 14 calendar days if the member requests the extension or if UCare justifies a need for additional information and the delay is in the member’s best interest. If UCare extends the deadline, the member is immediately notified verbally and in writing of the reason(s) for the delay.

An expedited grievance is a member’s complaint that UCare or one of its delegated entities refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. UCare must resolve these grievances within 24 hours of receipt.

Quality of Care Grievances

A quality of care complaint may be filed through UCare’s grievance process (See Quality of Care Review Process section in this chapter) and/or a Quality Improvement Organization (QIO).

If UCare receives a grievance about potential quality of care issues, a letter is sent to the member or representative with a summary of the issues and an explanation of the confidential peer review process. The letter also includes information on how to file a quality of care grievance with the QIO.

Quality Improvement Organization (QIO): An organization comprised of practicing doctors and other health care experts under contract to the federal government to monitor and improvethe care given to Medicare members. QIOs review complaints raised by members about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans and ambulatory surgical centers. A QIO determines whether the quality of services meetsprofessionally recognized standards of health care, including whether appropriate health care services have been provided and whether services have been provided in appropriate settings.

The member or their representative has the right to file a quality of care grievance with the QIOin the state where they reside.

Quality of care grievances filed with the QIO must be made in writing.

A member who files a quality of care grievance with the QIO is not required to file the grievancewithin a specific time period.

Below is the QIO where a UCare for Seniors or EssentiaCare member can file a quality of care grievance or seek additional information about the QIO’s review process:

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KEPRO5201 W Kennedy Blvd. Suite 900Tampa, FL 33609Phone: 855-408-8557 | Fax: 844-834-1730

A member who files a quality of care grievance with the QIO is not required to file the grievancewithin a specific time period.

Below is the QIO where a UCare for Seniors or EssentiaCare member can file a quality of care grievance or seek additional information about the QIO’s review process:

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KEPRO5201 W Kennedy Blvd. Suite 900Tampa, FL 33609Phone: 855-408-8557 | Fax: 844-834-1730

Minnesota Health Care Programs: Health Plan Appeals State Fair Hearings and Grievances

You can file an appeal with the health plan or request a hearing with a neutral state appeals representative if you have been denied a service, or a service has been reduced or terminated. You can also file an appeal or request a state fair hearing if the health plan is denying payment for a service you received.

• How do I file a health plan appeal?

• It is easy to appeal. You can simply call the health plan and tell them that you disagreewith their decision. The phone number is on the notice you received and on the back ofyour health plan ID card.

• The health plan can help you with your questions and help you file the appeal.

• You must file your appeal within 90 days of the action.

• You will receive a written decision within 30 days after you file the appeal.

• Health plans overturn many decisions on appeal.

• The ombudsman office can give you advice about filing an appeal.• Is your appeal urgent?

• If you want to appeal an urgently needed service, you can ask for a fast appeal.

• If the health plan agrees that the appeal is urgent, you will receive a decision within 72 hours.

• If the health plan disagrees that your appeal is urgent, you may file a grievance.• How do I file a request for a state fair hearing?

During a state fair hearing, a neutral state appeals staff person will listen to your concerns, consider the health plan information and make a written decision.

• You must request a hearing in writing within 30 days after the date of the notice you receivedtelling you they denied, reduced or terminated a service or a payment for a service you received.

• You have up to 90 days to file a state fair hearing if you have good cause for being late.

• If you want to continue receiving services while your appeal is being considered, you must file an appeal within 10 days after receiving the health plan notice.

• If you have information you want the appeal staff to see, you can include it with your State Agency Appeal form. If you receive any more related documents after you file your appeal, you must provide them to the state appeal staff and the health plan.

• The ombudsman office can help you request a state fair hearing and can advise you about how to prepare for your hearing.

You can submit your request online or by mail or fax. Complete the online or paper version of the Appeal to State Agency.

If you completed the printed form, mail or fax it to:

Minnesota Health Care Programs: Health Plan Appeals State Fair Hearings and Grievances

You can file an appeal with the health plan or request a hearing with a neutral state appeals representative if you have been denied a service, or a service has been reduced or terminated. You can also file an appeal or request a state fair hearing if the health plan is denying payment for a service you received.

• How do I file a health plan appeal?

• It is easy to appeal. You can simply call the health plan and tell them that you disagreewith their decision. The phone number is on the notice you received and on the back ofyour health plan ID card.

• The health plan can help you with your questions and help you file the appeal.

• You must file your appeal within 90 days of the action.

• You will receive a written decision within 30 days after you file the appeal.

• Health plans overturn many decisions on appeal.

• The ombudsman office can give you advice about filing an appeal.• Is your appeal urgent?

• If you want to appeal an urgently needed service, you can ask for a fast appeal.

• If the health plan agrees that the appeal is urgent, you will receive a decision within 72 hours.

• If the health plan disagrees that your appeal is urgent, you may file a grievance.• How do I file a request for a state fair hearing?

During a state fair hearing, a neutral state appeals staff person will listen to your concerns, consider the health plan information and make a written decision.

• You must request a hearing in writing within 30 days after the date of the notice you receivedtelling you they denied, reduced or terminated a service or a payment for a service you received.

• You have up to 90 days to file a state fair hearing if you have good cause for being late.

• If you want to continue receiving services while your appeal is being considered, you must file an appeal within 10 days after receiving the health plan notice.

• If you have information you want the appeal staff to see, you can include it with your State Agency Appeal form. If you receive any more related documents after you file your appeal, you must provide them to the state appeal staff and the health plan.

• The ombudsman office can help you request a state fair hearing and can advise you about how to prepare for your hearing.

You can submit your request online or by mail or fax. Complete the online or paper version of the Appeal to State Agency.

If you completed the printed form, mail or fax it to:

Minnesota Department of Human Services Appeals Division P.O. Box 64941 St. Paul, MN 55164-0941 Fax: 651-431-7523

• What is a grievance?

A grievance is the same as a complaint. Filing a grievance does not affect your health care program benefits. Examples of grievances include:

• The quality of care you received from a provider is not what you think it should be.

• You believe the health plan or a provider was rude to you.

• You believe your rights were not respected.

• You do not have sufficient access to providers.• How do I file a grievance?

You must file a grievance within 90 days of the event. Call your health plan member services and tell them what happened.

• You can file your grievance orally - you will receive an oral response from the health plan within 10 days.

• You can file your grievance in writing - you will receive a written response from the health plan in 30 days. If you need help writing your grievance, the health plan must help you.

• Where can I get more information about my rights and processes for appeals, state fair hearings and grievances?

See the following:

• Notice about Your Rights and Responsibilities for Minnesota Managed Health Care Programs - Medical Assistance and MinnesotaCare (PDF)

• Notice about Your Rights and Responsibilities for the Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (PDF)

• Notice about Your Rights and Responsibilities for the Minnesota Special Needs BasicCare Program (SNBC) (PDF)

Minnesota Department of Human Services Appeals Division P.O. Box 64941 St. Paul, MN 55164-0941 Fax: 651-431-7523

• What is a grievance?

A grievance is the same as a complaint. Filing a grievance does not affect your health care program benefits. Examples of grievances include:

• The quality of care you received from a provider is not what you think it should be.

• You believe the health plan or a provider was rude to you.

• You believe your rights were not respected.

• You do not have sufficient access to providers.• How do I file a grievance?

You must file a grievance within 90 days of the event. Call your health plan member services and tell them what happened.

• You can file your grievance orally - you will receive an oral response from the health plan within 10 days.

• You can file your grievance in writing - you will receive a written response from the health plan in 30 days. If you need help writing your grievance, the health plan must help you.

• Where can I get more information about my rights and processes for appeals, state fair hearings and grievances?

See the following:

• Notice about Your Rights and Responsibilities for Minnesota Managed Health Care Programs - Medical Assistance and MinnesotaCare (PDF)

• Notice about Your Rights and Responsibilities for the Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (PDF)

• Notice about Your Rights and Responsibilities for the Minnesota Special Needs BasicCare Program (SNBC) (PDF)