Case Management

Bradley Eckels, MA, LPC

Manager of Program Integrity

Christina Smouse

Program Integrity Auditor

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Why are there so many names for this level of care? The progression of case management.

Admission Criteria

Case Management Specific Documentation Requirements

Billable vs. Non-Billable Services

Beacon Minimum Documentation Requirements

Resources/References

Overview of Presentation

The Progression of Case Management

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• Targeted Case Management (TCM)

• Intensive Case Management (ICM)

• Resource Coordination (RC)

• Blended Case Management (BCM)

Why are there so many names for this level of care?

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Blended Case Management (BCM) – Revised OMHSAS-10-03(update to OMHSAS-09-02 which was rendered obsolete)

Targeted Case Management was separated into two distinct programs, Intensive Case Management (ICM) and Resource Coordination (RC). This system required a change in case managers when the consumer required a change in the level of case management service.

• A pilot project was initiated by OMHSAS to test the Blended Case Management Model. This model allowed the consumer to keep the same “blended case manager” even when there was a change in the level of service needs. The blended case manager would provide ICM or RC level of service as needed, essentially eliminating the distinction between RC and ICM in terms of service delivery.

• The Blended Case Management model was proven to increase continuity of care, decrease disruption in service, and allow consumers and families to focus more on goals. In December 2004, many county MH/MR programs began to implement the blended model of case management.

When did case management change?

Admission Criteria

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Any individual who qualifies for Intensive Case Management (ICM) or Resource Coordination (RC) level of case management, as specified in 55 PA Code 5221 , OMH-93-09, or Attachment Drespectively, shall be eligible for blended case management. Eligibility for at least resource coordination, as outlined below, will be the minimum eligibility requirement for blended case management.

A. Adults who have a serious mental illness as defined by meeting the criteria for Diagnosis, Treatment History, and Functioning Level:

1. Diagnosis: Diagnosis within DSM IV R (or succeeding revisions thereafter), excluding those with a principal diagnosis of mental retardation, psychoactive substance abuse, organic brain syndrome or a V-Code.

Admission Criteria

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2. Treatment History: Shall be established when one of the following criteria is met:

i. Six or more days of psychiatric inpatient treatment in the past twelve months;

ii. Met standards for involuntary treatment within the past twelve months;

iii. Currently receiving or in need of mental health services and receiving or in need of services from two or more human service agencies or public systems such as Drug and Alcohol, Vocational Rehabilitation, Criminal Justice, etc;

iv. At least 3 missed community mental health service appointments, or two or more face-to-face encounters with crisis intervention/emergency services personnel within the past twelve months, or documentation that the consumer has not maintained his/her medication regimen for a period of at least 30 days.

Admission Criteria Continued

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B. Adults who were receiving resource coordination, intensive case management, or blended case management services as children and were recommended by the provider and approved by the County Administrator or his/her designee, or the Behavioral Health Managed Care Organization, as applicable, as needing blended case management services beyond the date of transition from child to adult.

C. Children who have a mental illness or serious emotional disturbance as defined by meeting the criteria for Diagnosis, Treatment History and Functioning Level:

1. Diagnosis: Diagnosis within DSM IV R (or succeeding revisions thereafter) excluding those with a principal diagnosis of mental retardation, psychoactive substance abuse, organic brain syndrome or a V-Code.

Admission Criteria Continued

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2. Treatment History: Shall be established when one of the following criteria is met:

i. Six or more days of psychiatric inpatient treatment in the past twelve months;

ii. Without blended case management services would result in placement in a community inpatient unit, state mental hospital or other out-of-home placement, including foster homes or juvenile court placements;

iii. Currently receiving or in need of mental health services and receiving or in need of services from two or more human service agencies or public systems such as Education, Child Welfare, Juvenile Justice, etc.

Admission Criteria Continued

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D. An adult, child or adolescent who currently receives Intensive Case Management or Resource Coordination services.

E. An adult, child or adolescent who needs to receive blended case management services, but does not meet the requirements identified above, may be eligible for Blended Case Management upon review and recommendation by the County Administrator or his/her designee, or the Behavioral Health Managed Care Organization, as applicable.

*When asking for a waiver, you need to identify why the consumer

needs case management and how they can benefit from the service.

Admission Criteria Continued

Case Management Specific Documentation Requirements

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Documentation requirements as detailed in OMHSAS-12-03:

1. Intake Information

2. Assessments and Evaluations

3. Written Service Plan

4. Documentation of Services

5. Discharge Information

Documentation Requirements

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The following information shall be included in intake:

1. Identifying information to include the consumer’s name, address, date of birth, social security number, and third-party resources.

2. Referral form, to include date, source and reason for referral to TCM and diagnosis based on DSM IV-R, or subsequent revision.

3. Verification of eligibility to receive TCM, such as past treatment records, psychiatric or psychological evaluation, letter summarizing treatment history, Individual Education Plan (IEP), and any other relevant information.

Intake Information

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The following assessments and evaluations shall be made:

1. Medical history, taken within the past 12 months, or documentation of the blended case manager’s efforts to assist the consumer in obtaining a physical examination;

2. Assessment of the consumer’s strengths, needs, and interests;

3. Summaries of hospitalizations, incarcerations or other out-of-home placements while enrolled in blended case management, including the place and date of admission, reason for admission, length of stay, and discharge plan;

4. Children only: IEP, school testing - for example, psychological evaluations –guidance counselor reports, and the like, or documentation of the blended case manager’s efforts to obtain the information if not in the record;

Assessments and Evaluations

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5. Outcome information required for annual Consolidated Community Reporting Performance Outcome Management System reporting—that is, consumer level of functioning, independence of living, and vocational/educational status.

Environmental Matrix (EM):

• The EM is to be completed every six months at a minimum and whenever there is a change in level of service need.

• A change in the individual’s level of care should be communicated to all relevant agencies/providers involved in the member’s care.

Assessments and Evaluations Continued

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• In addition to the Environmental Matrix (EM), OMHSAS also expects the programs to use additional tools/methods to ensure appropriate level of service is provided. These tools/methods include, but are not limited to:

Consumer/Family input and inputs from other providers involved in the care;

Number of crisis contacts;

Current or anticipated stressors;

Use of program specific monitoring tools.

*Counties that have a previously obtained approval from OMHSAS to use the Combined Strengths Assessment Scale (CSAS) in place of the Environmental Matrix (EM) may continue to use the CSAS instead of EM.

Assessments and Evaluations Continued

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The plan shall:

1. Be developed within 1 month of registration with input from the consumer and reviewed at least every 6 months;

2. Reflect documented assessment of the consumer’s strengths and needs;

3. Be signed by the consumer, the family if the consumer is a child, the Blended Case Manager, the Blended Case Management Supervisor and others as determined appropriate by the consumer and the blended case manager. If the signatures cannot be obtained, attempts to obtain them should be documented;

4. Identify specific measurable goals, outcomes, and objectives. The service plan shall also identify responsible persons, time frames for completion and the Blended Case Manager’s role in relation to the consumer and others involved.

Written Service Plan

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The following shall be included in the record:

1. Case notes - the case notes shall:

• Be legible.

• Verify the necessity for the contact and reflect the goals and objectives of the Targeted Case Management Service Plan.

• Include the date, time and circumstance of contacts, regardless of whether or not a billable service was provided. Office of Mental Health and Substance Abuse Services (OMHSAS) is clarifying that “time” means indicating both start and end times (example: 9:30 am to 10:00 am), in order to validate units of service delivered.

• Identify the consumer by name or case number on both sides of each page on which there is writing on both sides. The consumer’s name and case number should appear together earlier in the file.

Documentation of Services

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• Be dated and signed by the individual providing the service

2. Documentation of referral for other services

3. Encounter forms

Documentation of Services continued

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The following shall be included:

a. A termination summary, including a reason for admission to blended case management, the services provided, the goals attained, the goals not completed and why, and a reason for closure. The summary shall:

i. Contain the signature of the consumer, the family if the consumer is a child, and involved others, if obtainable to verify agreement of the termination.

ii. Contain the signature of the county administrator/designee or the authorized representative of the Behavioral Health Managed Care Organization (as applicable) whether the consumer (or family, if the consumer is a child) consents to termination or not.

iii. Contain the signature of the county administrator/designee or the authorized representative of the Behavioral Health Managed Care Organization (as applicable) if the consumer requests termination but is at risk.

b. A recommended after-care plan.

Discharge Information

Billable/Non-billable Services

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Linking with Services

Monitoring of Service Delivery

Gaining Access to Services

Assessment and Service Planning

Problem Resolution

Informal Support Network Building

Use of Community Resources

Billable Services

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Case Manager travel time and time spent transporting or escorting consumers should not be billed as a unit of service.

Services performed outside the scope/duration/frequency as detailed in the service plan

Targeted Case Management (TCM) – Travel and Transportation Guidelines January 18, 2013 OMHSAS-13-01

Non-billable Services

Beacon Minimum Documentation Requirements

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The following slides will describe Beacon’s Minimum Documentation Standards for:

1. Consents to Treatment

2. Releases of Information

3. Service Plans/Treatment Plans

4. Progress Notes

5. Encounter Forms

Documentation Requirements

Consent to Treatment

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Consent to Treatment:

Name and signature of the member, or if appropriate, legal representative

Name of the provider (should correspond with license)

Type of services and/or treatment

Benefits and any potential risks

Alternative services and/or treatment

Date and time consent is obtained

Statement that services were explained to patient or guardian

Signature of person witnessing the consent (clinician, specialist, professional, or worker)

Name and signature of person who explained the procedure to the patient or guardian

Documentation Requirements Continued

Release of Information

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Release of Information:

A release of information must be completed prior to rendering services that allows Beacon to review the entire member chart for audit, quality, and payment purposes

Member’s name or Medical Assistance Identification Number

Date of release

Expiration of release

Dates of service range for the release

Statement that the complete member record including treatment information in service/progress notes and assessments will be released for audit, quality, and payment purposes

Signature of member or guardian and signature date

Clinician, specialist, professional, or worker’s signature, credentials, and signature date

Documentation Requirements Continued

Service Plan/Treatment Plan

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Service Plan:

Must be completed according to service requirements

Service/rehabilitation/recovery plan date

Strengths and needs specific to the member’s diagnosis and/or functional impairments

Clinician, specialist, professional, or worker’s signature, credentials, and signature date

Evidence member or guardian participated with service/rehabilitation/recovery plan development

Goals and objectives based on referral and assessments of the member’s strengths and needs

Documentation Requirements Continued

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Service Plan Continued:

Service goals are measurable

Service goals have established timeframes

Service/rehabilitation/recovery plan is easy to read and understand

Service/rehabilitation/recovery plan documents necessity for services

Service/rehabilitation/recovery plan documents the utilization of services, such as frequency and time

Service/rehabilitation/recovery plan reviews must be completed with the member or guardian’s signature and signature date

Documentation Requirements Continued

Progress Note

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Progress Note:

Must be completed for each billable encounter

Name or Medical Assistance Identification Number

Date of service

Start and stop times of service

Units match the claims billing

Place of service (specific location for community services)

Reason for the session or encounter specific to member’s needs

Service goals addressed

Description of services provided by clinician, specialist, professional, or worker

Member’s response to service goals and objectives

Documentation Requirements Continued

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Progress Note Continued:

Next steps and plans for continued services

Narrative with the justification to support utilization and time billed

Supporting documentation, when applicable

Includes the signature of the individual, or if the individual does not sign, documents the reason (Psych Rehab services only)

Clinician, specialist, professional, or worker’s signature, credentials, and signature date

Documentation Requirements Continued

Encounter Form

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Encounter Form:

Must be completed for each billable encounter (except for crisis and indirect services)

Member name including member identification number (as required in the PA Medicaid Bulletin)

Type of service

Date with start and stop times

Total units billed

Signature of member for each encounter

Clinician, specialist, professional, or worker’s signature, credentials, and signature date

Documentation Requirements Continued

Resources/References

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Please reference the PA State Regulations listed below and on the next slide for all Case Management Service Requirements.

Chapter 5221. Mental Health Intensive Case Management December 21, 1990

https://www.pacode.com/secure/data/055/chapter5221/055_5221.pdf

Resource Coordination: Implementation OMH-93-09, July 30, 1993

http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_003708.pdf

Blended Case Management (BCM) - Revised OMHSAS-10-03 June 14, 2010

http://dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_006966.pdf

Resources/References

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Attachment D – Blended Case Management Guidelines

http://dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_006970.pdf

Mental Health Targeted Case Management (TCM) Documentation Requirements June 14, 2012 OMHSAS-12-03

http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_005999.pdf

Targeted Case Management (TCM) – Travel and Transportation Guidelines January 18, 2013 OMHSAS-13-01

http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/p_033890.pdf

Resources/References Cont.

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Beacon Health Options Services Tab

http://www.vbh-pa.com/services/

Beacon Health Options Provider Manual

http://www.vbh-pa.com/providers/provider-manual/

Beacon FWA Webpage

http://www.vbh-pa.com/fraud-waste-and-abuse/

Beacon Minimum Documentation Requirements

Therapeutic & Rehabilitation Services

http://s18637.pcdn.co/wp-content/uploads/sites/9/Therapeutic-and-Rehabilitation-Services.pdf

Resources/References Cont.

Bradley Eckels, MA, LPCManager of Program Integrity

Beacon Health Options724-744-6520

Bradley.Eckels@beaconhealthoptions.com

Christina SmouseProgram Integrity AuditorBeacon Health Options

724-744-6584Christina.Smouse@beaconhealthoptions.com

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Thank you