BUMEDINST Nov 2009

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2 Government (including those provided by the DoD, VA, Department of Labor, and the Social Security Administration), references (f), (g), and (i). As appropriate, Navy case managers shall support these programs. Enclosure (1) provides a list of acronyms used in this instruction. Enclosure (2) provides Web sites used in this instruction. 5. Definitions. The Case Management Society of America defines case management as a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet complex health needs through communication and available resources to promote quality, cost-effective outcomes. 6. Case Management Structure/Responsibility a. Bureau of Medicine and Surgery (BUMED)-M00WII CM (Program Manager) (1) Provides program oversight, support, and resources. (2) Develops CM Policy: (a) Determines and issues standards of care for CM. (b) Outlines required training and education. (c) Establishes standards for documentation. (d) Establishes standards for workload management. (e) Develops process and outcome metrics to accurately report CM activity across the Navy Medicine enterprise. (3) Serves as subject matter expert (SME). (4) Collaborates with TRICARE Management Activity, civilian organizations, VA, and other DoD activities. b. Regional Commanders shall (1) Ensure the provisions of this instruction are followed. (2) Facilitate collaboration between Regional medical treatment facilities (MTFs), TRICARE Regional Office, and their respective networks, VA, civilian organizations, and DoD activities. (3) Collect and forward monthly the following data to BUMED CM Program Manager: 2

3 (a) Total number of case managers. (b) Number of patients receiving facility-based CM services. (c) Number of active duty personnel receiving CM services through Service-specific wounded warrior programs (e.g., Navy Safe Harbor and Marine Corps Wounded Warrior Program). (d) Acuity (reference (h), Appendix E Coding Case Management Services). (e) Case-mix (reference (a), DoD TRICARE Management Activity, Medical Management Guide, Section II, Case Management, Jan 2006). services. (f) Number of wounded, ill, or injured (WII) service members receiving CM (g) Outcome reports showing the effectiveness of clinical CM. (4) Collect and report quarterly the number and percentage of case managers who have completed required training. c. MTF Commander/Commanding Officer (1) Provides logistical support, staffing, and funding to meet the mission requirements. (2) Ensures that comprehensive care, treatment, and administrative services are provided in a multi-disciplinary, collaborative manner. (3) Prioritizes the populations to be served by CM based upon MTF business plan, BUMED or Regional policy and patient requirements. (4) Shall comply with Command responsibilities as outlined in reference (i), the MOU between BUMED and the Navy Safe Harbor Program. d. MTF CM Department Head/Division Officer (1) Ensures CM activities and standard operating procedures (SOPs) meet policy requirements. (2) Prepares a variety of workload and administrative reports as related to CM efforts, and submits in a timely manner. (3) Functions as SME for command on CM issues. 3

4 (4) Evaluates the effectiveness of CM from clinical, quality, and economic perspective. (5) Keeps MTF commander and higher authority informed of activities, trends, and issues to include data to be reported to the Navy Medicine Region such as: (a) Total number of case managers. (b) Number of patients receiving facility based CM services. (c) Number of active duty personnel receiving CM services through Service-specific Wounded Warrior Programs (e.g., Navy Safe Harbor and Marine Corps Wounded Warrior Program). (d) Acuity (reference (h), Appendix E Coding Case Management Services). (e) Case mix (reference (a), DoD TRICARE Management Activity, Medical Management Guide, Section II, Case Management, Jan 2006). (f) Number of WII service members receiving CM services. (6) Ensures clinical case managers document and code their services in the Armed Forces Health Longitudinal Technology Application (AHLTA) using DoD-established provider specialty codes, Health Insurance Portability and Accountability Act (HIPAA) taxonomy codes, Medical Expense Performance Reporting System (MEPRS) codes, diagnosis codes, and Healthcare Common Procedure Coding System (HCPCS) codes. (7) Educates members of the health care team on CM program benefits and outcomes. (8) Supervises case managers to ensure standards of practice are being met per policy. (9) Serves as resource/educator and consultant to command about CM program. (10) Identifies and appropriately monitors WII service members receiving CM services. (11) Monitors the precision and timeliness of intake and transfer transitions. (12) Provides documentation oversight/review for all MTF CM. (13) Develops and deploys comprehensive performance measures to ensure appropriate and effective implementation of clinical CM. (14) Monitors the effectiveness of CM interoperability with all Service personnel systems. Service-specific CM programs shall be interoperable with apparent seamlessness for the WII service member. 4

5 (15) Ensures all training and competencies are completed as required. BUMEDINST (16) The NAVMED 6300/18, Case Manager Documentation Review, provides the template for the review of the CM process for all case managers. It is required that a minimum of 10 percent of active cases or 5 records, whichever is greater, be reviewed monthly for 6 months of hire, then reviewed quarterly for every case manager. Peer review reports shall be maintained by the department head or CM supervisor for a period of 7 years. 7. CM Goals and Objectives. The goals and objectives of CM must be in alignment with the DoD, Department of Navy (DON), appropriate directive authorities, BUMED, and MTF strategic plans. The goals of CM are to: a. Provide the appropriate level of care (e.g., care coordination, discharge planning, and other CM services) for those individuals requiring special assistance (e.g., WII service members, children, and/or elderly population). b. Manage the health care of TRICARE beneficiaries with multiple, complex, chronic, and catastrophic illnesses or known conditions. c. Coordinate transfer of information with the managed care support contractor (MCSC) case managers when patients require care outside the Direct Care System. d. Communicate with other medical management personnel (utilization management, referral management, and disease management). e. Ensure a seamless transition from one duty station to the next for selected family members enrolled in the Exceptional Family Member Program (EFMP). f. Coordinate a warm hand-off between the MTF the case manager and the VA case manager for all service members transferring to the VA system. g. Enhance continuity of care and decrease fragmentation by providing education, developing strategies, and intervening when required to restore or maintain optimal health. 8. CM Process includes: a. Identification/Case Finding/Case Screening. Screening will enable the case manager to determine the patient s need for CM. If the beneficiary does not meet criteria to receive CM services, the person is referred back to the originator of the referral with suggested resource alternatives. (1) Sources of identification may include: (a) Review of: 5

6 1. Admission and disposition lists (MTF and MCSC). 2. Daily inpatient census (MTF and MCSC). 3. AHLTA and Composite Health Care System (CHCS) ad hoc reports (e.g., readmissions, long-term patient, pharmacy usage, etc.). 4. Emergency department/urgent care rosters. 5. Navy/Marine Corps Wounded Warrior reports. 6. Population Health Navigator. units. 7. Medical Transition Company (Active Duty) and Medical Hold (Reserve) 8. Medical claims, (i.e., multiple visits to an emergency department). (b) Communication with multi-disciplinary team after daily inpatient ward rounds. (c) Communication with EFMP coordinators. sources: 1. Primary care manager (PCM) or specialty care providers (network or nonnetwork). (d) Referrals that are screened within 24 hours or 1 business day from the following 2. Patient (self-referral). 3. Family/significant other/caregiver. 4. Utilization management, disease management, and/or discharge planners. 5. Recovery Care Coordinator (RCC), Federal Recovery Coordinator (FRC), or Wounded Warrior Program representative (i.e., non-medical CM (NMCM)). (2) Beneficiaries in any of the following categories shall be screened for CM: (a) WII who meet the following criteria: 1. Category 1 (CAT 1) a. Has a mild injury or illness. b. Is expected to return to duty in less than 180 days. c. Receives primarily local outpatient and short-term inpatient medical treatment and rehabilitation. 6

7 2. Category 2 (CAT 2) a. Has a serious injury or illness. b. Is unlikely to return to duty in less than 180 days. c. May be medically separated from the military. 3. Category 3 (CAT 3) a. Has a severe/catastrophic injury or illness. b. Is highly unlikely to return to duty. c. Will most likely be medically separated from the military. (b) Multiple medical providers. (c) Catastrophic illnesses or injury. (d) Chronic or terminal illness. (e) Multiple medical problems/dual diagnosis (medical and psychiatric). (f) Lack of family/social support. (g) Non-adherence to treatment. (h) Multiple visits to the emergency department. (i) Transplant, high-risk or high-cost. (j) Special interest. (k) Functional/physical deterioration. (l) Frequent utilization of health care resources. (m) High-risk obstetrics. b. Assessment is a systematic, ongoing process of collecting comprehensive bio-psychosocial information about a beneficiary s situation (including all relevant sources, military and civilian) to identify needs. This assessment is completed within 3 business days of accepting the patient into CM. c. Planning is collaboration with the patient and family, to determine specific goals, objectives, and actions to meet the particular needs of the patient. The Initial Care Plan is completed within 7 days of the initial assessment. The Comprehensive Care Plan is completed within 30 days of initiating assessment. Key elements include: 7

8 (1) Design care plan with action oriented goals with designated time frames which are specific to the beneficiary s needs. (2) Identify immediate patient support systems. (3) Advocate for the patient and family as needed. (4) Identify actual and potential resources. d. Implementation is a process of executing interventions identified in the plan of care that will lead to accomplishing/achieving the stated goals. (1) Communicate with the patient and family to assure their understanding of the care plan as well as their critical role in the care plan. (2) Communicate the care plan to the health care team members. (3) Document in AHLTA the treatment progress and any modifications of the plan as appropriate. (4) When indicated, communicate the patient s medical care plan to the RCC for inclusion into the comprehensive recovery plan. e. Coordination is the process of organizing, securing, integrating, and modifying resources necessary to accomplish the care plan goals. (1) Avoid duplication of services. (2) Ensure timely and appropriate provision of services. (3) Identify barriers to care delivery and exploring alternatives. (4) Match patient needs with available resources. (5) Optimize health care resources in the MHS, TRICARE, and VA communities to address targeted needs. (6) Organize and manage the activities outlined in the care plan. (7) Coordinate with the TRICARE regions, wounded warrior programs, RCCs, FRCs, VA Medical Facilities, Military Medical Support Office (MMSO), civilian health care facilities, and any venue where TRICARE beneficiaries receive care. 8

9 f. Monitoring is the ongoing process of gathering information from relevant sources with regard to activities and services to determine effectiveness in achievement of planned clinical outcomes. (1) Ensure timely and appropriate care is provided based on the patient s changing health status and/or environment. (2) Ensure timely patient/family contact and follow-up. (3) Establish and document outcome measurements. (4) Identify variance(s) from the treatment/care plan. (5) Monitor results of interventions and care delivery. (6) Monitor utilization of health care resources. g. Evaluation is the process, repeated at appropriate intervals throughout the entire CM process, of determining the plan s effectiveness in reaching the desired outcomes and goals. (1) Appropriateness of patient needs and plan of care. (2) Clinical outcomes for efficacy of care. (3) Cost savings and/or cost avoidances for the patient, family, and MTF. (4) Customer and health care team satisfaction. (5) Effectiveness of the CM Program. (Did the patient meet the defined goals? Were the goals realistic? Were the goals measureable? Was the plan cost effective? Was there a return on investment?) (6) Impact of CM interventions on population health/disease management. (7) Stability of the patient/family home environment. 9. Documentation a. All CM documentation will be placed into AHLTA using the designated standardized template when applicable. Entries must be accurate, relevant, timely, and complete. b. Each patient note will be coded per TRICARE Management Activity Guidelines. 9

10 c. Each patient receiving CM will have a signed consent by the patient or patient representative. If authorization is provided telephonically, a witness must be present and sign verifying consent was given. Refer to DD Form 2870, Authorization for Disclosure of Medical or Dental Information. 10. Transition of Care. When a beneficiary under CM transfers to another facility or region, it is the responsibility of the transferring and gaining case managers to ensure a smooth transition. Prior to transfer, an accepting physician must be identified and accept the patient. As the patient transitions to an outpatient setting, it is highly encouraged not only to identify the accepting physician, but also to obtain an appointment with the identified physician, coordinate the medical record transfer, and communicate the date/time of the appointment to the patient/family. If a gaining case manager cannot be identified, the case must be maintained within the originating CM program. a. Criteria to consider for transitioning of care include: (1) Permanent change of station orders, temporary assigned duty orders, and assignment to another MTF. (2) Change of catchment area or PCM which may result in reassignment of a case manager. (3) Patient request for different case manager. (4) Patient s care needs exceed that of the MTF and is transferred to another level of care to maintain continuity. b. Responsibilities of the case managers during transfer: (1) Obtain authorization from MMSO for a patient transfer from a civilian hospital to a VA facility. (2) Obtain authorization from the MCSC for a patient transfer from the MTF to a VA facility. (3) Communicate and coordinate transfer with discharge planners, and non-medical case managers, FRCs, and RCCs as appropriate. (4) Document according to the standards of practice set forth by the Case Management Society of America. (5) Upon transfer, the transferring case manager communicates with the gaining case manager at the accepting facility and documents the discussion within the CM notes in AHLTA. 10

11 (6) The transferring case manager s responsibilities do not stop until the gaining case manager accepts the responsibility of the patient. (7) The following shall be documented within the case manager s notes in AHLTA: (a) Diagnosis or medical condition that prompted the need for CM services. Include a summary of the patient s current medical status. (b) Date of transfer. (c) Reason for transfer. (d) Mode of transfer. (e) Accepting case manager and physician. (f) A brief summary of the care received and potential future needs. Include a copy of the Discharge Summary Form, explain the patient s administrative requirement (e.g., Physical Evaluation Board (PEB)), and change in benefits, and forward an electronic copy of diagnostic studies as appropriate. (g) For inter/intra-regional transfers, consider using NAVMED 6300/13, Inter/Intra Regional Transfer Documentation Active Duty Service Member (ADSM) or NAVMED 6300/14, Inter/Intra-regional Transfer Documentation Non-Active Duty Service Member (Non-ADSM). (h) For any education provided to the patient/family member, include notation of references provided. Consider using NAVMED 6300/15, Patient s Information. (i) Complete forms NAVMED 6300/16, Case Management Discharge Planning Assessment and NAVMED 6300/17, Checklist for Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF). 11. Workload Management. Per reference (a), the DoD Medical Management Guide, the case load for CM ranges from 10 to 50 patients per case manager depending on acuity. To ensure facilities and clinics are adequately staffed with case managers, a weekly workload report (Secretary of the Navy Report) is required and submitted to the BUMED CM program leads. 12. Case Manager Training and Competencies. MTFs shall provide appropriately trained case managers to support WII service members and all TRICARE Prime beneficiaries. a. Education. Case managers must be either licensed registered nurses or licensed social workers. 11

12 b. Certification. It is strongly encouraged that case managers become certified in CM within 3 years of hire. The case manager (nurse or social worker) has the option to obtain certification by the following organizations. All other certifications shall require approval and waiver based on level of education required, work experience, and continuing education requirements for recertification. (1) Commission for Case Management Certification (CCMC): the Certified Case Manager (CCM). (2) American Nursing Credentialing Center (ANCC): the Registered Nurse-Board Certified (RN-BC). (3) National Academy of Certified Care Managers (NACCM): Care Manager Certified (CMC). (4) National Association of Social Workers (NASW): Certified Social Work Case Manager (C-SWCM). c. Basic CM training, to be completed within 3 months of hire. Contents of the basic training shall include: (1) Completion of the case manager core competencies. Competencies shall be reviewed on an annual basis. The organization must have education and training plans to provide initial and subsequent competency review. It is recommended that the newly oriented case manager conduct a self-assessment at the beginning of orientation. (2) Training in proper documentation in AHLTA and appropriate coding. (3) Training in the role of the case manager in utilizing a patient-centered approach to clinical CM (including the involvement of the WII service member and their family in developing a multi-disciplinary plan of care). (4) Training in common combat-related injuries. (5) Training in transition of care coordination. (6) All case managers shall complete the required education and training modules, as they become available, using the MHS Learn training platform, available at: Forms and Reports a. DD Form 2870 (DEC 2003), Authorization for Disclosure of Medical or Dental Information is available electronically from the Department of Defense forms Web site at 12

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14 ACRONYMS ADSM AHLTA ANCC BUMED C-SWCM CCM CCMC CHCS CM CMC CRP DoD DON DTM EFMP FRC HCPCS HIPAA MCSC MEPRS MMSO MOU MTF NACCM NASW NMCM OIF/OEF PCM PEB RCC RN-BC RSM SME SOP URAC VA WII Active Duty Service Member Armed Forces Health Longitudinal Technology Application American Nursing Credentialing Center Bureau of Medicine and Surgery Certified Social Work Case Manager Certified Care Manager Commission for Case Management Certification Composite Health Care System Case Management Care Manager Certified Comprehensive Recovery Plan Department of Defense Department of Navy Directive-Type Memorandum Exceptional Family Member Program Federal Recovery Coordinator Healthcare Common Procedure Coding System Health Insurance Portability and Accountability Act Managed Care Support Contractor Medical Expense Performance Reporting System Military Medical Support Office Memorandum of Understanding Medical Treatment Facility National Academy of Certified Care Managers National Association of Social Workers Non-Medical Case Manager Operation Iraqi Freedom/Operation Enduring Freedom Primary Care Manager Physical Evaluation Board Recovery Care Coordinator Registered Nurse-Board Certified Recovering Service Member Subject Matter Expert Standard Operating Procedures Utilization Review Accreditation Commission Department of Veterans Affairs Wounded, Ill, or Injured Enclosure (1)

15 WEB SITES Department of Defense (DoD) TRICARE Management Activity, Medical Management Guide, Section II, Case Management, Jan Case Management Society of America, Standards of Practice, Utilization Review Accreditation Commission (URAC), Case Management Standards Joint Commission Standards Under Secretary of Defense for Personnel and Readiness Directive-Type Memorandum (DTM) , Recovery Coordination Program: Improvements to the Care, Management, and Transition of Recovery Service Members (RSMs) Appendix E Coding Case Management Services SECNAV M of Dec MHS Learn Training Platform Enclosure (2)