Texas Department of State Health Services Case Management for Children and Pregnant Women Online Provider Tutorial Script - Final As Produced

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1 GRAPHIC: HELPING CASE MANAGERS HELP THEIR CLIENTS DSHS Logo Case Management Logo (Still montage of children and families in need of case management services.) AUDIO: (Subtle music or sound effects intro) This tutorial is designed to augment your case management training. It provides an overview of case management services and offers guidance on ways you can help clients find and get the services they need. Your Case Management for Children and Pregnant Women Training Manual is the comprehensive resource on case management policies and rules. It also contains helpful explanatory information and examples of case scenarios. You might want to take notes during this tutorial when we reference specific parts of the manual so you can refer back to it later. From your work as a case manager, you are very aware that families of children with health conditions or health risks and women with highrisk pregnancies often have an array of healthrelated needs. Such situations are challenging for anyone. For many clients and families with minimal resources, they are simply overwhelming. Without access to needed services, client health outcomes could be compromised. (Stills of people who represent Case Management providers in various settings) (Video) Animation of navigating the systems: health care Will it cover this? Will it cover that? social service agencies, schools, paperwork Case Manager [new video] That s why your role as a case manager is crucial. Providing case management services for clients and families helps ensure they find and get services they have difficulty finding on their own. In the many ways you provide assistance and support, you are helping alleviate barriers to accessing health-care services and enabling your clients to move through the continuum of health care. You wear many hats as case managers. You are coordinators, facilitators, mentors, and advocates. Your work includes teaching clients and families how to navigate health-care, social service, and educational systems, in order to find and get the services they need. Sometimes when we talk with a new client or family, they don t understand what our role is. They might be skeptical or confused. They may have had contact with caseworkers from other 1

2 programs and don t know the difference between what we do. It s helpful to be able to explain the difference. [Still images to illustrate these other caseworkers) CASE MANAGEMENT ELIGIBILITY [Idea: is there a way to use the eligibility algorithm appended to the end of the script for a graphic step-by-step in this section?] (Text appears when spoken): 1. Medicaid eligible 2. Birth through age 20 with a health condition/ health risk or high-risk pregnancy at any age 3. Need help accessing services 4. Want case management services (Slides) Eligibility Requirements Medicaid Eligibility chipmedicaid.org Here are a few examples of caseworkers or case managers with whom your client may have had contact. When applying for Medicaid, the client was assigned a Medicaid caseworker to provide assistance. Some clients and families have interacted with a social worker in relation to a hospital stay. Others have worked with case managers involved with health plans, community agencies, or school. You can briefly walk them through how your work differs from that of these others and describe the scope of your case management services. A case manager must accept all referrals for case management; however, not all referrals meet the eligibility criteria. Section 3 of your Training Manual addresses eligibility requirements. You can find details about each of the four requirements there. It s helpful to consult the manual if you have a question about eligibility. We ll take a few minutes here to provide some tips for considering whether a referral is eligible during intake. To be eligible for case management services, the client must: One: Be Medicaid eligible. Two: Be a child from birth through age 20 with a health condition or health risk. or a woman of any age with a high-risk pregnancy. Three: Need help accessing services related to his or her health condition or health risk or high-risk pregnancy; and Four: Want case management services. For most referrals, the clients are already receiving Medicaid, but a client does not have to be enrolled at the time of intake. You may assist the client with enrollment, but until enrollment is completed, you cannot file a claim. The CHIP/Medicaid website at chipmedicaid.org is a good source for Medicaid eligibility guidelines, and it has an income eligibility calculator. Clients can 2

3 Medicaid 101 txhealthsteps.com Health condition/health risk/high-risk pregnancy Need help accessing services Want case management services Client s Must Meet All Eligibility Criteria also apply online from the website. A good resource for case managers about Medicaid in general is the online provider education course titled Medicaid 101. The training is free and offers CEU credit. It s available at txhealthsteps.com. While some clients referred to you do have a medical diagnosis, a diagnosed condition is not required for a case management referral. For instance, a pre-teen who s begun to exhibit behavioral problems atypical of same-age peers may not have yet had a mental health assessment or diagnosis. Some health risks don t even involve a medical diagnosis. Such would be the case for a pregnant woman experiencing domestic abuse, which puts both her and her baby at risk. You cannot diagnose a client nor make a determination that specialty care is needed, but you can help the client make an appointment for a potential diagnosis or referral to a specialist when the primary care physician makes that recommendation. The need for accessing services must have an impact on the client s health status as related to a health risk or condition or a high-risk pregnancy. For instance, such a need exists if a client must travel distances to receive medical care and cannot afford transportation. Another applicable case is when a client has been prescribed medical equipment or supplies, but has not been able to get them. What if a client needs special accommodations at school due to a disability, but does not know how to work out arrangements? This would also qualify as a need for services that affects the client s condition. Clients are not required to accept case management. You must be sure the client and family want your assistance. You may receive a referral in which the client only meets some of the criteria. For example, the client may be Medicaid eligible, may want case management, may have a health condition, but the client does NOT meet the requirement for a medically necessary medical, social, educational, or other need. In another case, the client may be Medicaid eligible, may want case management, but does NOT have a health condition, health risk, or high-risk pregnancy. 3

4 (Image) Case Manager with client/family (Slides) THE 5 STEPS STEP 1 Does the client have a health condition, health risk, or high-risk pregnancy? STEP 2 Does the client have psychosocial factors that are affecting the health condition or risk, or high-risk condition? STEP 3 Does the client have needs related to the health condition or risk, or high-risk condition? STEP 4 Does the need involve overcoming a barrier or requiring assistance in order to access services? During the initial intake, the case manager must carefully assess the situation with the client and family and determine if the referral meets all requirements. Here is a tool that can help you assess eligibility and document concrete needs that link back to a health condition or risk. This tool will also help you when submitting your request for prior authorization for case management services. We call it The Five Steps. They are really tips for asking questions to elicit the information you need to make a thorough and accurate assessment. Step One: Does the client have a health condition, health risk, or high-risk pregnancy? Your training manual provides information on what can constitute a health condition or risk, or the health issues that make a pregnancy high risk. Another source of information is the online provider education course titled Case Management. It s also available at txhealthsteps.com and offers free CEU credit. Step Two: Does the client have psychosocial factors that are affecting the health condition or risk, or high-risk condition? Psychosocial factors might be alcohol or drug abuse, or homelessness, among others. These factors are not necessary for eligibility but may contribute to the health risk or ability to get needed services. Step Three: Does the client have needs related to the health condition or risk, or high-risk condition? These could be medical needs (including doctor visits, developmental testing, or medical equipment); educational or vocational needs (including special education or transition planning); social needs (such as financial assistance or transportation); or other needs (including mental health services or respite). Step Four: Does the need involve overcoming a barrier or requiring assistance in order to access services? Are the needs current or anticipatory? If there is a barrier or a current need for assistance, the client may be eligible. 4

5 STEP 5 Does the client/parent/guardian want case management services? SERVICE PLAN DEVELOPMENT Case Manager B [from Case Management Video] (Slides) Listen Ask open-ended questions and clarifying terms Document clear, concise, and objective goals Establish who will accomplish each goal Provide relevant information SERVICE PLAN COMPONENTS Step Five: Does the client/parent/guardian want case management services? You may have to probe to get the answer. Establishing a service plan with the family is a primary function of case management. Since the service plan is based on the family s needs, no two services plans are exactly alike. Different conditions and needs call for different solutions. With each family we re looking at the whole picture, not just at the pregnant woman sitting in front of us or the child with the health condition sitting in front of us. We re looking at all of the issues which may affect the child or the pregnant woman, including the home and family environment. So it s a whole array of issues that affect families who just don t know where to find services and don t know how to get the resources that are out there. As you develop the service plan, here are some things to remember. Listen to what your client is saying about his or her concerns. Clarify issues or concerns by asking open-ended questions and using clarifying terms. Don t leave issues or needs vague. Document clear, concise, objective goals. You and the client, parent, or guardian need to understand and agree on these goals. Ensure everyone is certain about who will accomplish each goal. Developing the service plan is a collaborative effort with the client and family. It s not just about what we can do for them. We help clients identify where they need help and where they are equipped to handle things on their own. Provide relevant information that responds to your client s needs and concerns. What you do for them is individualized, not generic. The most important component of case management is ensuring that the client s needs 5

6 Back to Case Manager [new video] SERVICE PLAN COMPONENTS (slide stays on the screen as components dissolve in/out) Coordinating Services COORDINATING SERVICES [stethoscope, wheelchair, van, school building, telephone] PROVIDING APPROPRIATE REFERRALS [pen writing] ASSISTING WITH APPOINTMENTS [appointment calendar] FINDING RESOURCES [screen shot from Resources PPT The How-To of Finding Resources are met. It is essential that all the activities you conduct either address or resolve the needs of the client. A family s service plan may include some or all of these components. Coordinating services related to medical and dental care, durable medical equipment and supplies, transportation for health-care visits, multiple service providers, Medicaid managed health care plans, and educational or school services. Providing appropriate referrals to community resources, to other Medicaid benefits, or to mental or behavioral health services. Before giving your client a referral, you must call ahead to ensure that it is an appropriate referral and that they are accepting clients. Always make sure that the client has a choice in the referrals provided. They need options to choose what works best for them. Assisting with getting appointments that are convenient for work, school, or transportation schedules. Convenience is not the only issue. A client may need your help advocating for an appointment with the appropriate provider or facility when barriers exist. Finding local resources to assist with family needs and psychosocial issues related to the client s health condition or risk. Section 2 of your Training Manual covers some of the most commonly used resources for case management clients. You can find detailed information there on programs and services. As other case managers will tell you, knowing HOW to find proper resources for your clients is half the solution. The how-to involves taking time to research available resources and confirm that the information you find is current and accurate. The best way to do this is to call or the resource ahead of time to verify the information, inquire if there is a waiting list, and confirm the application process, if applicable. For this kind of research, you can utilize the Texas Information and Referral Network, search websites, and call or other community contacts. You can also call on DSHS Regional Staff 6

7 Website screenshots Community Contacts DSHS Regional Staff Medicaid Waiver Programs ATTENDING MEETINGS [people around a conference table] for suggestions on locating community resources. You ll need to research specific issues relevant to your client base and the typical resources that address those issues. Familiarize yourself with health conditions and risks, especially If the condition is new to you. Spend some time researching the conditions as well as the resources available to support people with that condition. For example, many case management clients may be eligible for Texas Medicaid waiver programs. These programs provide community-based services and supports for people with disabilities. Each waiver program has different rules and funding amounts. Consult Section 2 of your training manual for details on the waiver programs. Attending meetings with a client and parent or guardian. Among the most common are Admission, Review, and Dismissal (ARD) Meetings for preschool children with disabilities and special education students. Case managers may attend meetings of local Community Resource Coordination Groups (CRCGs) to help develop individual service plans for clients with complex needs who need multiple agency services. There are two excellent resources on the special education process. The Guide to the Admission, Review and Dismissal Process contains information that parents need to participate effectively in an ARD committee meeting. Legal Framework for the Child-Centered Process in Texas is an electronic template that summarizes state and federal requirements for special education by topic. Both of these resources are available online at ADVOCATING FOR YOUR CLIENT S BEST INTERESTS [megaphone] Advocacy is a major element of case management. You should advocate for clients at the service-delivery, benefits-administration, and policy-making levels. This may involve speaking on your client s behalf with entities such as his or her managed care plan, referring physician, program intake staff, and school personnel. 7

8 These steps can help you be an effective advocate to make systems work better for your clients and their families. (Slides) Define the problem Gather information Plan course of action Act assertively Follow up Define the problem clearly and specifically, and separate facts from feelings. Remember that complex situations may involve several different problems. Gather the type of information needed for the type of problem at hand, then analyze it. Are there policies, rules, or laws that apply? Plan your course of action to resolve the problem. It may include one step or several. Identify who will help you and each person s role. Act assertively and use assertive communication involving active listening and negotiation. Follow up to make sure the problem resolution agreement has been reached or implemented. If not, you may need to repeat steps with a different approach. Be sure to document all of your efforts. Document all efforts Case Manager A [from Case Management video] Here s how one case manager used her advocacy and service coordination skills to help resolve several client needs. Recently I worked with a family who has a 6- year-old with cerebral palsy and other health conditions, and he is non-ambulatory. Well he had outgrown his wheelchair and the mother wasn t quite sure how to order a new one. So with her consent, I contacted the child s physical therapist at the school, who also agreed, he did need a new wheelchair. And the physical therapist and I worked together. We contacted the medical supply company that the mother had used before. They got the necessary paperwork from the child s doctor, and the physical therapist did a seating 8

9 evaluation. Now this child has a new wheelchair. His mother was also not aware that Medicaid would cover his diapers, so I also requested that the medical supply company contact his doctor about a prescription. Now he gets his diapers through Medicaid. As case managers, we work to coordinate services and to be an advocate if needed. At the assessment, his mother brought up that his speech therapy hours at his school had recently been reduced. So I explained to her that she could ask for a school meeting, and I would be there with her as an advocate for her son. So we have a meeting this next week with the school. And these are just some of the things that I did with this family. But every family is different, so we look at what each family individually needs. Case Manager [new video] FOLLOW-UP (Still of client/cm meeting) (Still of CM on the phone) Your work as a case manager isn t done until you follow up with clients to make sure their needs have been addressed or resolved. We want to make a distinction here between follow-up visits, which area part of case management and are billable, and ongoing monitoring, which is not. During a follow-up visit, you must review the entire service plan with the client/parent/guardian to determine if the needs have been met and if outstanding needs still exist. If needs exist, you must problem-solve with the client/parent/guardian to identify ways to address or resolve the service plan need. Look at Section 3 of the training manual to see more details on follow-up and case resolution. Back to Case Manager [new video] WHAT CASE MANAGEMENT IS NOT As important it is to know what case management is, it s also important to know what it is not. Case management is not a referral service, nor is it a gatekeeper service. Neither is it a service to provide medical care or other clinical care. And, as we said earlier, it is not monitoring or checking in with clients. Through research, we found that awareness of 9

10 COMMUNITY OUTREACH Case Manager [new video] case management is limited. Outreach is key to educating both potential clients and referral sources about the availability and benefits of case management. Outreach is also beneficial to your professional practice. We know that building a business is hard work, and we know it takes time and patience to educate potential clients, health-care providers, and local resources about your services. However, no one knows your community better than you. Providing outreach for case management services not only helps make your business a success by generating referrals to you, but also enables you to meet the demands and needs of more children with health conditions and women with high-risk pregnancies. In basic terms, community outreach is the practice of conducting local public awareness activities with targeted audiences. Any outreach activity you conduct must ensure that resulting case management referrals will be individualized to client need and support client choice. ALLOWABLE OUTREACH ACTIVITIES (add subtitles below as they are spoken) Educating Service Providers Community Networking These are allowable outreach activities. Educating service providers in the community. Such activities include: - Visiting local service providers, such as doctors, therapists, school counselors, health clinics, and family centers. - Making presentations to hospital, community agency, and service provider staff. - Visiting with staff at local Women, Infants & Children (WIC) clinics and other governmental offices, daycare centers, rehab/home health agencies, and other locations that provide services to children with special health needs and pregnant women. - Providing case management materials to display in offices. Networking in the community, including: - Visiting with local agency staff. - Attending local interagency, coalition, and committee meetings. - Building relationships with key personnel at organizations likely to make referrals. 10

11 (Still photo of two people at lunch, with new VO to serve as case manager speaking this is from quote in research report) (New VO-different from Narrator) Educating potential clients through health fairs or media. This could include: - Setting up a display where people can ask about services. - Placing ads and articles about case management. These must be approved in advance by DSHS. Educating Potential Clients (Text) PROHIBITED OUTREACH ACTIVITIES (Rotate in and out the following images): Knocking on door Handing out pamphlet List of names Incentives! written on page Agreement written on page Because these outreach activities could hinder client choice, they are prohibited: Conducting door-to-door, telephone, or other cold call marketing or solicitation of clients. Distributing false or misleading materials. Obtaining lists of Medicaid clients without specific referral. Offering incentives for enrollment into case management. Entering into exclusive relationships or agreements with referral sources. From the long list of allowable outreach activities, you can see that you have many options. Developing an outreach plan will help you figure out what works best for you. (Text) OUTREACH MATERIALS (Still montage of case management materials) Brochures Posters Online Ordering asp DSHS has developed a number of informational materials about case management. We encourage you to use them. Brochures and posters are designed for individuals who are potentially eligible for case management services. These materials can help you explain case management to both referral sources and clients. You can them order online at: Though you may develop your own materials, they must be approved by DSHS before you distribute them. Such materials might include brochures, fliers, advertisements, and websites. Any of your own materials should include these items: Case management eligibility criteria. Description of case management services. 11

12 Title of the program. The THSteps ( ) hotline. (Opening clip from new video) Online Provider Education txhealthsteps.com PROVIDER INFORMATION dshs.state.tx.us/caseman/provider.shtm CLIENT INFORMATION dshs.state.tx.us/caseman/clientpg.shtm THANK YOU CENTRAL OFFICE CONTACT INFORMATION dshs.state.tx.us/caseman/contact4.shtm A video designed for use in educating health-care professionals and community agencies is available through DSHS. You may order it by ing DSHS at AskCM@dshs.state.tx.us The Case Management online provider education course is also a source of information that can help you explain case management to clients and referral sources. Refer back to your Training Manual and your DSHS Regional Staff liaison for training needs or technical assistance. You can use the case management Provider Information page on the DSHS website as your portal to case manager forms, training schedules, policies, and rules. You can send potential clients and referral sources to the website s Client Information page for program details. Thank you for taking the time to learn more about providing case management services to Medicaid clients. DSHS Case Management Consultants are always available to answer your questions. You can find their phone numbers and addresses on the Central Office Contact Information page of the DSHS website. Closing Credits 12