Section 15.0 - Care Management for Serious Mental Illness (SMI) Members 15.1.1 Introduction 15.2.1 Scope 15.3.1 Objectives 15.4.1 Procedures 15.4.1-A. Responsibilities 15.4.1-B. Eligibility 15.4.1-C. Member Identification for Care Management 15.4.1-D. Case Analysis Review (CAR) 15.4-1-E. Condition Specific Review Tool 15.4.1-F. Care Planning 15.4.1-G. Case Updates 15.4.1-H. Case Rounds 15.4.1-I. Criteria for Discharge from the Care Management Program 15.4.1-J. Program Oversight and Responsibilities 15.1.1 Introduction The care management program has been designed to improve member healthcare outcomes by providing needed care in the most appropriate setting in a culturally competent and accessible format. The care management program s primary goals are: Identify the top tier of high risk/high cost members with serious mental illness who would benefit from a fully integrated health care program; Effectively transition members from one level of care to another; Streamline, monitor and adjust members care plans based on progress and outcomes; Reduce hospital admissions and unnecessary emergency department and crisis service use; and Provide members with the proper tools to self-manage care in order to safely live work and integrate into the community. 15.2.1 Scope This section applies to all providers rendering services to the SMI members. 15.3.1 Objectives This section describes the responsibilities, eligibility, and requirements of care management. 15.4.1 Procedures 15.4.1-A. Responsibilities Mercy Maricopa s Chief Medical Officer (CMO) is responsible for directing and overseeing Mercy Maricopa s care management program with the assistance of the Medical Management Administrator and the Director of Care Management. This oversight includes ensuring the Page 15.0-1
incorporation of treatment practice guidelines into the care management practice and program. 15.4.1-B. Eligibility Mercy Maricopa s care management program is available to enrolled members who qualify for the care management program, are Title XIX, categorized as having a serious mental illness, and who qualify for the care management program. The assessed needs of the member determine the level and type of care management. Typical members are those who: Are at high risk of poor health outcomes and high utilization; Have an acute or chronic diagnosis or condition; Have inappropriately managed their health care, and require more complex or frequent healthcare and services. 15.4.1-C. Member Identification for Care Management Mercy Maricopa utilizes data from multiple sources to identity members who may benefit from care management to meet their individualized needs. These tools allow for members to be stratified into a case registry and their specific risks identified, including chronic co-morbid conditions and specific gaps in care. Members may be identified through population-based tools (i.e., predictive modeling) and individual-based tools (i.e., Health Risk Assessment [HRA]). These tools include the following: CORE Report (predictive modeling) Health Risk Assessment On a monthly basis, HRAs are incorporated into predictive modeling reports to further identify members that may need care management. These reports also assist in identifying the appropriate care management level, particularly for those members with the greatest potential for improved health outcomes and increased cost-effective treatment. In addition, members are identified for care management through various referral sources from within Mercy Maricopa and through external sources. These referral sources include, but are not limited to, the following: Member self-referral Family and/or caregiver Interdisciplinary Team (IDT) Utilization Management (UM) referral Quality Management (QM) referral Various other Mercy Maricopa departments Discharge planner referral Provider referral Provider submissions of the American College of Obstetricians and Gynecologists [ACOG] comprehensive assessment tool Page 15.0-2
Provider submission of an Early Periodic Screening, Diagnosis, and Treatment (EPSDT) tracking form Division of Behavioral Health Services (DBHS) AHCCCS Department of Economic Security (DES)/Division of Developmental Disabilities To make a referral to the Care Management program, contact 800-564-5465, Option 2 for Provider Calls then Option 6 for a Behavioral Health Representative. Upon receipt of referral, Mercy Maricopa s Care Management department will assess the member s eligibility against the aforementioned criteria and provide written notification of placement decision within 30 days of referral. 15.4.1-D. Case Analysis Review (CAR) If eligible, the assigned care manager completes an initial member CAR within thirty (30) calendar days of the determination of eligibility for care management and quarterly thereafter until the member is discharged from the care management program. The CAR includes the following items at a minimum: A medical chart review to identify member current health status, current providers service utilization, specific gaps in care Consultation with the member s treatment team Review of administrative data, including claims and encounter data Demographic and customer service data Root cause analysis as to over/under utilization Medication review, including updating a member medication list Placement review, including updating a member placement history Based on the CAR, the member s stratification level may be modified to best meet their needs. 15.4-1-E. Condition Specific Review Tool Upon completion of the CAR, specific disease conditions may be noted. If the member has any chronic conditions such as, asthma, diabetes, or Hypertension, the care manager is to complete the corresponding condition specific assessment. 15.4.1-F. Care Planning The information gleaned from the CAR is used in the development of a member centric plan of care that is streamlined and supports the member s physical and behavioral health, social and community service needs, placement goals and preferences. All members enrolled in the care management program shall have a care plan. The care manager and members of the treatment team each participate in the development of the care plan which is designed to prioritize goals that consider the member s and caregiver s strengths, needs, goals, and preferences. Page 15.0-3
The care management plan at a minimum shall include the following elements: Member demographics Identification of the member s treatment team Member conditions Member s/family s vision Identified protective factors Identified barriers Interventions recommended to the treatment care team, including responsible party and target date for completion Coordination gaps and strategies to improve care coordination, including an identified responsible party(ies) Strategies to monitor referrals and follow-up for specialty care and routine health care services, including medication monitoring. Each follow up item includes an identified responsible party(ies) The care plan shall align with the member s Individual Recovery Plan/Individual Service Plan, but shall be neither a part of nor a substitute for that plan. As part of the care planning process, the care manager documents a schedule for follow up with the treatment team and convenes care plan reviews at intervals consistent with the identified member care needs and to ensure progress and safety. Care plan reviews are pre-scheduled and designed to evaluate progress toward care plan goals and meeting member needs. The care plan can be revised/adjusted at any point based on member progress and outcomes. The care plan identifies the next point of review and is saved in the member s electronic record in the care management business application system. 15.4.1-G. Case Updates Coordination of care and service needs occurs regularly to ensure efficient utilization and to avoid any gaps or duplications in services. When care plans are reviewed, the need for care plan updates, a change in level of care management, and ongoing care management needs are evaluated. Care plans are verbally shared and are also mailed to the care team and/or made available via Mercy Maricopa s secure portal. To encourage involvement by the treatment team, the care manager facilitates communication across various disciplines and care settings within and outside Mercy Maricopa, including the SMI clinic, primary care practitioner (PCP) or health home and any other health or service providers who work with the member to deliver services and ensure comprehensive care. This may be done through site visits, phone calls, written communication, or in-person interdisciplinary care team conferences. Page 15.0-4
The treatment team supports the care planning process by providing an array of expertise that helps the team coordinate and integrate fragmented services to best address each member s individual needs within the context of their family, circle of supports, and cultural community. Together they: Coordinate care across the spectrum of the health care system including managing transitions between levels of care. Assist in early identification of changes in health status of members. Provide self management training and health education to members and circle of supports regarding conditions and psychosocial behaviors. View the member s situation as a whole, including all supports, caregivers, family members, and significant others, as well as the environment in which they live. Assure that behavioral health, social and functional needs are met. Identify and coordinate the provision of community resources and non covered services. Utilize evidence-based practices that can connect at-risk individuals to care via the use of well-defined action steps that are designed to produce healthy outcomes. Aim to provide member-centered care management. 15.4.1-H. Case Rounds A member s unique care needs can also be addressed through formal interdisciplinary case rounds. In case rounds, both treatment and non-treatment staff may present cases to their peers and treatment leaders to seek guidance and recommendations on how to best address the member s physical, behavioral and social care needs. Case rounds typically focus on members who are at high risk, have complex co-morbid conditions and/or have difficulty sustaining an effective working relationship with treatment and/or non-treatment staff. Case rounds may also include representatives from the member s treatment team. Case rounds are done bi-weekly, twice a month. 15.4.1-I. Criteria for Discharge from the Care Management Program Discharge from care management is considered whenever: Care plan goals have been met including stabilization of the member s condition, successful links to community support and education, and improved member health. The member has received maximum benefit from care management. Member is no longer enrolled in the Title XIX SMI program and needs to be transitioned to new programs. Member death. 15.4.1-J. Program Oversight and Responsibilities Mercy Maricopa s CMO is primarily responsible for directing and overseeing the care management activities and processes with the intention of supporting continuous process improvement. The Utilization Management Committee supports the Care Management Department and the CMO s activities to continuously monitor the performance of the care Page 15.0-5
management team and the care and services they provide to members. A population assessment is conducted annually to assess the characteristics and needs of the member population and relevant subpopulations, and includes, but is not limited to, number of members, gender, age and top ten (10) diagnoses. The population assessment is evaluated against the care management program, procedures and resources and is updated if necessary, to address member needs. The information is included in the yearly Care Management Evaluation. Outcome reports are done monthly. Page 15.0-6