Care Transitions Training Videoconference December 17, 2009 Questions and Answers

Transcription

1 1. Q: Will the transition log be sent to the counties and care systems electronically? A: It will be available on each health plan s Web page. If a website is not available, the plan will send the form to its Delelgates. 2. Q: What can we expect to get from hospitals and ERs? Will they send us a discharge summary? A: The contractual arrangements/requirements between each hospitals and ER are unique to specific health plans. Please note that ER visits are not considered a transition that you would need to document. 3. Q: Is an acceptable reason for being late too busy? A: Each Health Plan/Delegate is responsible for these requirements. Reasons for failure to meet the requirements should be documented. For example, you might say, delay due to inability to reach the member/physician (left message,) or phone disconnected. 4. Q: Are we expected to contact the Primary Care Physician by telephone or letter? A: Either is acceptable. 5. Q: Once the log is filled out, do we fax it to the health plan? A: NO, it should be retained in the member s file. 6. Q: How do we get the information to CMS? A: The health plans are responsible for analysis of data, auditing the logs, and reporting to CMS. 7. Q: We have electronic charting in our county so the Primary Care Physician (PCP) is notified of a transition via the IT system. Do we still need to notify the hospital and/or the PCP? A: It depends on whether or not the hospital has access to the electronic system, as not all hospitals are connected to a specific group s electronic charting. 8. Q: Is it acceptable to fax notification to the PCP? A: Yes 9. Q: Do we track mental health, psychiatric hospitalizations, or chemical dependency inpatient treatment? 10. Q: Who are ICF staff? A: Staff from an Intermediate Care Facility for persons with Developmental Disabilities (ICF/MR) 11. Q: Can we add home care agencies to the list? A: We have added it to the log. Thank you for the suggestion. 12. Q: The care transition log is missing the description area A: We have added it to the log. Thank you for the suggestion. Page 1 2/5/2010

2 13. Q: In terms of follow-up with the member, do you have to contact the member in the nursing home or hospital? A: Yes, that is the requirement. 14. Q: Does the care plan have to be mailed or faxed? A: No, pertinent information from the care plan can be shared verbally, such as services currently being received by the member and who provides them, who the PCP is, diagnosis, special health needs of the member, etc. 15. Q: Who is the transition support person? A: In most cases it is the Care Coordinator. A care system, such as a clinic, could designate a lead person other than the assigned Care Coordinator to handle care transitions. 16. Q: XYZ County is a very rural area and the chances are good that the PCP is the referring physician for the hospitalization. Doctors consider this additional notification an annoyance; they are swamped with paperwork as it is. A: If the admitting Doctor is the PCP, you do not have to notify the Doctor that the patient was admitted, the Doctor is already aware. Please note that on the form. 17. Q: Do we need to verify the PCP knows about the admission? 18. Q: Is it okay to notify the PCP s clinic instead of the PCP? 19. Q: If the member is admitted to a nursing home, do we still notify the PCP? If the PCP is aware of the transfer, just make a note in the log. 20. Q: What is assisted living considered on the log? A: The community residence. 21. Q: As a long-term care coordinator, do we expect to get information from the nursing home? A: Some nursing homes will notify you, others will not. 22. Q: Have the health plans done education with hospitals, facilities, and PCP so they are aware this is coming? What was their response? This doesn t make sense, PCP s either have the information or they do not want it. A: Health plans have and will continue to educate providers and members about health plan expectations. Delegates should contact their health plan if they experience difficulty implementing this requirement with a particular provider. 23. Q: Is the PCP reimbursed for reading this and following up? A: That depends on the health plan contract. Page 2 2/5/2010

3 24. Q: Does fee-for-service MA have to do this? A: No. This is a CMS (federal) requirement for Special Needs Plans like MSHO and SNBC. Medicaid FFS is not a Special Needs Plan. 25. Q: We fear we may lose the respect and cooperation of our Doctors by asking them to do more work. A: Care Coordinators are simply informing PCPs of admissions/transitions and not necessarily asking them to do additional work. 26. Q: If the member goes from a nursing home to the hospital and back to the nursing home who do we have to notify? A: Each transition is documented separately. With each transition you would communicate with the receiving facility (first the hospital and then nursing home) and the member and/or their guardian. You would also notify the PCP of the admission. 27. Q: What if our member has dementia? A: It is acceptable to talk to the authorized representative or the social worker. 28. Q: Why a policy to notify PCP s? A: Care Coordinators are considered the link between the different care sites, ensuring communication and coordination of services. CMS views the PCP as a key individual to coordinate the various medical aspects of care; providing them with information about admissions and discharges is very important. 29. Q: Will the health plans be giving the Care Coordinators additional information on hospitalizations? A: Each health plan has their unique system for notification with care systems and counties. Please check with your health plan. 30. Q: If the County does CADI for an SNBC member, but not SNBC coordination do we have to log their transitions? A: No, the SNBC Care Coordinator does the tracking and log. 31. Q: What if we are notified two months after the member is back at home and the PCP knows the member was discharged. A: Make a comment in the comment section of the PCP notification even if you don t know the dates. 32. Q: Is electronic notification sufficient? 33. Q: As a Care Coordinator who works with mental health and CD cases, do I need to get a signed release to share information with PCP? A: We believe it is part of the health plan s contract with the state and you do not need a release. Page 3 2/5/2010

4 34. Q: If I need to get a release, is that an expectable reason for being late? A: Yes; document this on the log. 35. Q: Does this transition apply to MSC+? A: Some plans require this. Others view it as a best practice. Please check with your plan. 36. Q: Please clarify the purpose and expectation regarding communications for the long term nursing home resident. Per nursing home regulation and protocol if the primary physician has not been personally involved in the hospital admission/discharge they will be informed of it. In the nursing home setting the nursing home staff have the role of care coordinators. We do not make care arrangements. If I am to communicate with the nursing home, hospital and resident/representative what exactly is to be the content of these communications, particularly when I may not know about it until several months later when I am doing a review. A: The CMS requirements are identical for members living in the community and in an institution such as a nursing facility. The goal or purpose of the Care Coordinator s transitional services across settings is to reduce incidents related to fragmented or unsafe care and reduce readmissions for the same condition. If you know that the PCP has been notified, document this in the log once it has been verified. Due to the unique features of an institutional setting (i.e. regulatory requirements) your communication may be as much to inform yourself of the member s needs as it is to share their needs with the facility. 37. Q: I d find it helpful to have the timelines written somewhere on the Log, so we can easily be reminded of our responsibility (i.e. bottom of page or in right hand upper corner) A: Thanks for the suggestion. We have added it. 38. Q: I do the SW for the hospital, nursing home and Hospice. I am assuming that the actual care coordinator for the health plan completes this. A: Yes, you are correct. 39. Q: I would like to do a couple scenarios with you. I have a managed care pt come to the hospital they are admitted who contacts the case manager that they are admitted is that me? A: The information can come from a variety of sources but it would be wonderful if you did call the care coordinator. They often do not know someone is hospitalized in a timely fashion. 40. Q: Does then the Care Coordinator keep in contact with me and fill out the form? A: Yes, the Care Coordinator completes the form and keeps it in the member s file. 41. Q: How about the person who comes into the ER and is admitted to another hospital or nursing home. Is the case manager contacted? A: Again, anytime you can let the Care Coordinator know of an admission, it is extremely helpful. 42. Q: What if it is on a weekend and they are only there a day or two. A: You can leave a message for the Care Coordinator; you do not need to connect personally. 43. Q: If they are in the nursing home and go to the hospital I would let the care manager know. Page 4 2/5/2010

5 A: Yes 44. Q: Is this done per or a faxed form? Let me know how this is supposed to work. A: If you have secure and know the address of the Care Coordinator, you can contact them that way. Telephone is probably the easiest. Otherwise you cold fax as well. We have not developed any specific forms for this. 45. Q: Which members are the ones we need to notify - only MSHO pts, PMAP? A: This is required for all Special Needs Plans, which includes Minnesota Senior Health Option (MSHO) and Special Needs Basic Care (SNBC.) Some health plan may also be requiring it for Minnesota Senior Care Plus (MSC+) member; please check with your health plan. PMAP is not concluded, as these members do not receive care coordination. 46. Q: The examples did address activities and documentation when the care coordinator is not notified regarding a change in the member s setting. However, the question has been raised what if the care coordinator learns about the change in setting (typically a hospitalization) months later. This is actually not uncommon and especially when it is a very brief stay. Would you still complete the communication and follow up activities. A: Yes, you would follow up with the member to see if they have any questions, the nature of the hospitalization, what follow up they did, and determine if you need to do any updates to the care plan or follow up. For example, the hospitalization may have been due to a fall and you may need to do an environmental assessment of their home for scatter rugs, etc. or it may have been due to a problem associated with a chronic condition they have. You may follow up with a referral to disease management or it may prompt a discussion of how they are taking care of that chronic condition. You would also notify the PCP (probably the PCP s nurse) of the hospitalization. 47. Q: If the member is on a waiver there could potentially be waiver case management and care coordination. The client s waiver services would be a critical component in coordination. Would it be the responsibility of the managed care coordinator to complete the transition log and also notify the waiver case manager? A: Yes, there should be regular communication between the two workers to coordinate services. The MSHO/SNBC Care Coordinator is responsible for completion of these requirements and documentation. 48. Q: Is the tracking log discussed at the recent ITV required or can our agency use another format if it tracks all the needed info? A: The information on the log is required. If you have an electronic charting system and can produce a report with the same information, that is acceptable; otherwise you must use the log. 49. Q: Does your agency require we track just Medicare eligible persons or do you require we track all enrollees?(non Medicare as well as Medicare?) A: All enrolled MSHO and SNBC enrollees must be tracked. Contact your health plan for MSC+ requirements. 50. Q: Do hospitalizations from nursing home to hospital and return to nursing home need to be tracked? Page 5 2/5/2010

6 A: Yes, they are transitions from the member s usual setting based on a change in health condition. 51. Q: What is our definition of business day? A: 1 business day means that tasks needs to be completed by the end of the next (8 hour) work/business day. A business day does not include Saturdays, Sundays, or holidays. 52. Q: We have a question regarding what to do if there is a member that is having a care transition and their care coordinator is gone ie: sick leave, vacation, involved with other screenings or home visits. The agency may receive notification of a transition, but the care coordinator may not receive the notification until their return to the office which may be more than one business day from the agency notification of transition. At what point should another care coordinator take over and review the case and try to assist with the transition? A: CMS holds each health plan, as an organization, responsible for meeting these requirements and timelines (regardless of who at that health plan is assigned the particular task.) In this instance, health plans are delegating this responsibility to care systems and counties contracted to provide care coordination services. Each county or care system will need to make sure there is a system in place to ensure that timelines and requirements are met when the assigned Care Coordinator is not able to provider the service, whether it is because of other meetings/responsibilities, vacations, or sick time, etc. 53. Q: Another question is regarding reaching out to member prior to admission or day of admission. Some of us care coordinators feel a bit uncomfortable about reaching out to the member on the day of admission. The day of admission is usually filled with a surgical procedure or numerous medical tests, facility staff communicating with member, sleep inducing pain medication etc. We feel like we could potentially be an intrusion rather than a helper by contacting the member on the day of admission. Also, many members moving into nursing facilities do not have telephones hooked up in their rooms on the day of admission. Some members do not have authorized reps. A lot of communication in the past has been done with the member through the hospital discharge planner or social worker at a facility. The discharge planner has been able to determine when the best time is to communicate with the member and address issues regarding the discharge with the member. We are wondering if the Care coordinator could determine on a case by case basis whether the member should be contacted directly by the care coordinator during a transition. It could depend on the person s health status or how long a care coordinator has been working with a member the member s level of comfort and familiarity with the care coordinator. Thinking back to times I ve been in the hospital, I m quite certain that I would not have liked to receive a call to my hospital bed from someone from my insurance company. A: Most likely the Care Coordinator would not be aware of a planned admission (and thus able to reach out to the member prior to the admission) unless there was an existing relationship between the member and Care Coordinator. CMS sees the Care Coordinator as the key person to assist the member through the transition process, helping to reduce incidents related to fragmented or unsafe care and reducing the likelihood of rehospitalizations for the same condition. CMS does require the Care Coordinator to have direct contact with the member for the purpose of explaining the Care Coordinator's role and how to contact them during their stay and/or after their return home and to talking to the member about what happened, changes in health status, what might occur while in the Page 6 2/5/2010

7 hospital/nursing home, and any discharge plans leading to or delaying discharge. This must be done within 1 business day after notification of the admission so it does not need to be done on the day of admission. Care Coordinators will still work with the discharge planners on many of the specifics related to discharge. 54. Q: We have cases in which the person goes to the ER and they keep the person for 23 hours for observation. Do we log this too? We have 2 hospital discharge planners that sometimes call us about these situations because they do not know if they are safe at home and this is especially true if the person has many trips to the ER. But yet they can not be admitted. A: Technically it would be an ER visit and not a true admission so we would not require communication and transition dates to be documented on the log. You could, however, choose to document your involvement on the log and just indicate it was an ER observation or document in your case notes. Page 7 2/5/2010