CASE MANAGEMENT DOCUMENTATION

How Do We Meet the DSHS Service Standards Measures?

June 26, 2019

ACUITY USE AND DOCUMENTATION –MCM ONLY

ACUITY SCALE SCORING

MCM ACUITY DOCUMENTATION TO MEET THE STANDARD

• The two monitoring indicators we will focus on here are:

• Percentage of MCM clients with documented evidence of an acuity level using an

approved acuity scoring tool with the comprehensive assessment in the primary record

system

• Percentage of MCM clients with documented evidence of review of acuity at a

minimum of every three (3) months to ensure acuity is still appropriate level for the

client’s needs

ACUITY DOCUMENTATION EXAMPLE 1

ACUITY DOCUMENTATION EXAMPLE 1

ACUITY DOCUMENTATION EXAMPLE 2

ACUITY DOCUMENTATION EXAMPLE 2

UPDATED ACUITY DOCUMENTATION

• How does this look in monitoring?

• Acuity for clients accessing MCM services, at a minimum, should be updated every

three (3) months, right?

• If the client acuity was scored in January 2019, when would the monitoring team expect

to see an updated acuity tool?

• Answer: April 2019

• If the client acuity was scored in January 2019, and the client declined MCM services,

when would the monitoring team expect to see an updated acuity tool?

• Answer: So long as it was documented that the client decline services, the monitoring team

would not expect to see an updated acuity tool

UPDATED ACUITY DOCUMENTATION

ASSESSMENT OF MCM PRIORITY NEED• MCM Assessment

• MCM Performance Measure in the Standard:

• Percentage of clients who access MCM services

that have a completed initial comprehensive

assessment within 30 calendar days of the first

appointment to access MCM services and

includes all required documentation in the

primary client record system.

ASSESSMENT OF NMCM PRIORITY NEED

• NMCM Performance Measure in the

Standard:

• Percentage of clients who access NMCM

services that have a completed

assessment within 30 calendar days of

the first appointment to access NMCM

services and includes all required

documentation.

MCM ASSESSMENT EXAMPLE

• This is one example of a comprehensive initial assessment entered in ARIES:

COMPREHENSIVE ASSESSMENT EXAMPLE

• What about this assessment? Does it provide detail to determine client needs? Would

this client require MCM or NMCM services?

COMPREHENSIVE INITIAL ASSESSMENT

• What about this example?

CREATING A CARE PLAN• Elements of a Care Plan (minimum standards):

• Developed Care Plan (MCM and NMCM) Monitoring Indicator:

• Percentage of MCM or NMCM clients with documented evidence that a Care Plan was developed and

contains all of the following:

• Problem statement/need

• Goal(s)

• Intervention (tasks, referral, service delivery)

• Responsible party for the activity

• Timeframe for completion

CARE PLAN EXAMPLES

• The following example did not met the monitoring standard for a developed care

plan. Can you pick out why?

CARE PLAN EXAMPLEBelow is an example of a initial developed Care Plan. Does this meet the Standard

requirement for minimum documentation?

UPDATING CARE PLANS• MCM Monitoring indicator:

• Percentage of MCM clients with documented evidence of an updated care plan with

outcomes and that has been revised or amended in response to changes in client life

circumstances or goals, at a minimum, every six (6) months.

• NMCM Monitoring indicator:

• Percentage of NMCM clients with documented evidence that the care plan was

developed and/or updated two or more times in the measurement year.

• How are these indicators monitored? What documentation do we need?

UPDATED CARE PLAN EXAMPLE

• Let’s go back to this example:

UPDATED CARE PLAN

• Now it’s your turn! Does this care plan meet the indicator for an updated care plan?

CASE NOTES

• Case notes provide the detail and background for the assessment/reassessment of

the client’s needs. In addition, case notes tell the story from day 1 to day ??? of all

activities completed both by the case manager and by the client to help achieve the

tasks and goals in the care plan.

• Client education is an integral part of ensuring clients’ knowledge increases

throughout the course of providing case management services.

• Let’s start with the education requirements in the DSHS MCM Service Standard.

MCM SERVICES EDUCATION DOCUMENTATION

• The MCM monitoring indicator for education provided is listed below:

• Percentage of MCM clients with documented evidence of education (appropriate to

age) provided to each client which includes all of the following:

• Medication adherence

• HIV disease process

• Risk reduction/prevention strategies, including substance abuse

• Nutrition

• Oral Health

• There are several ways a case manager can meet this indicator in their

documentation during a monitoring review……let’s explore some examples…..

CASE NOTE EXAMPLE - EDUCATION

• ARIES documentation of education provided during the assessment phase:

CASE NOTE EXAMPLE - EDUCATION

CASE NOTE EXAMPLE - EDUCATION

MONITORING NOTE

In areas/regions where Referral for Health Care Services is not a funded service and

case managers are limited to only entering service units based on their job title, if a

client intake is completed and the client does NOT require or declines case

management assistance, enter the service unit as either:

Case Management (non-medical)>Intake-No CM or

Medical Case Management (including treatment adherence)>Intake-No CM

ROLE PLAY

• Have an example of a few potential clients

• Have case managers within their tables determine who will be the ‘client’

• Document an acuity based on the case managers’ interview with the client

• Complete an assessment

• Create a care plan

• Go around the room and have volunteers discuss their acuity and care plan

documentation, how they determined what the client needed, how they interviewed,

questions asked, how did they determine MCM vs NMCM, how did their care plan

look