MI HP Ca se Ma na g e me nt a nd Qua lity I mpro ve me nt Oc to - PowerPoint PPT Presentation

MI HP Ca se Ma na g e me nt a nd Qua lity I mpro ve me nt Oc to b e r MI HP Co o rdina to r T ra ining s 2017

Go a ls o f this Pre se nta tio n  Ca se Ma na g e me nt De finitio ns  Ca se Ma na g e me nt Guiding Princ iple s  Ma te rna l I nfa nt He a lth Pro g ra m Go a ls  Co nc e pts o f Ca se Ma na g e me nt a pplie d to MI HP Se rvic e s  Qua lity I mpro ve me nt

Ca se Ma na g e me nt De finitio ns

De finitio n o f Ca se Ma na g e me nt : NCQA A c o lla b o ra tive pro c e ss o f a sse ssme nt, pla nning , fa c ilita tio n, c a re c o o rdina tio n, e va lua tio n a nd a dvo c a c y fo r o ptio ns a nd se rvic e s to me e t the c o mpre he nsive me dic a l, b e ha vio ra l he a lth a nd psyc ho so c ia l ne e ds o f a n individua l a nd the individua l’ s fa mily, while pro mo ting q ua lity, c o st-e ffe c tive o utc o me s. So urc e : NCQA 2016 He a lth Pla n Sta nda rds a nd Guide line s

De finitio n o f Co mple x Ca se Ma na g e me nt  NCQA He a lth Pla n Sta nda rds  De finitio n: A pro g ra m o f c o o rdina te d c a re a nd se rvic e s fo r o rg a niza tio n me mb e rs who ha ve e xpe rie nc e d a c ritic a l e ve nt o r dia g no sis tha t re q uire s e xte nsive use o f re so urc e s.  E xa mple s: hig h risk OB, dia b e te s, a sthma So urc e : NCQA 2016 He a lth Pla n Sta nda rds a nd Guide line s

De finitio n o f Ca re Co o rdina tio n  T he de lib e ra te o rg a niza tio n o f pa tie nt c a re a c tivitie s b e twe e n two o r mo re pa rtic ipa nts (inc luding the pa tie nt) invo lve d in the pa tie nt’ s c a re to fa c ilita te the a ppro pria te de live ry o f se rvic e s.  I nvo lve s o rg a nizing pe rso nne l a nd o the r re so urc e s ne e de d to c a rry o ut a ll re q uire d pa tie nt c a re a c tivitie s  Ma na g e d b y e xc ha ng ing info rma tio n a mo ng pa rtic ipa nts So urc e : CMSA, Sta nda rds o f Pra c tic e fo r Ca se Ma na g e me nt

Guiding Princ iple s o f Ca se Ma na g e me nt

Ca se Ma na g e me nt  E nsure s c a re is sa fe , e ffe c tive , c lie nt-c e nte re d, time ly, e ffic ie nt, a nd e q uita b le  E nha nc e s se rvic e s b y ma inta ining c lie nt priva c y, c o nfide ntia lity, he a lth, a nd sa fe ty thro ug h a dvo c a c y a nd a dhe re nc e to e thic a l, le g a l, a c c re dita tio n, c e rtific a tio n, a nd re g ula to ry sta nda rds o r g uide line s  Ac hie ve s o ptimum va lue a nd de sira b le o utc o me s fo r a ll sta ke ho lde rs So urc e : Co mmissio n fo r Ca se Ma na g e r Ce rtific a tio n (CCMC)

Philo so phy o f Ca se Ma na g e me nt  Ca se ma na g e me nt se rve s a s a me a ns fo r a c hie ving c lie nt we llne ss a nd a uto no my thro ug h:  Advo c a c y  Co mmunic a tio n  E duc a tio n  I de ntific a tio n o f se rvic e re so urc e s  Se rvic e fa c ilita tio n  Re so urc e ma na g e me nt  Ac c o mplishe d thro ug h:  Dire c t c o mmunic a tio n b e twe e n the c a se ma na g e r, c lie nt, me dic a l c a re pro vide rs (e .g ., PCP, OB, MHP), pa ye rs, a nd o the r se rvic e de live ry pro fe ssio na ls  Go a l is to o ptimize he a lth o utc o me s thro ug ho ut c o ntinuum o f c a re So urc e : Ca se Ma na g e me nt So c ie ty o f Ame ric a

Ca se Ma na g e me nt: Unde rlying Pre mise  E ve ryo ne b e ne fits whe n c lie nts re a c h the ir o ptimum le ve l o f we llne ss, se lf-ma na g e me nt, a nd func tio na l c a pa b ility  Sta ke ho lde rs inc lude :  Clie nts se rve d  Clie nt suppo rt syste ms  He a lth c a re de live ry syste ms, inc luding pro vide rs o f c a re ; e mplo ye rs a nd pa ye rs So urc e : Co mmissio n fo r Ca se Ma na g e r Ce rtific a tio n (CCMC)

Ma te rna l I nfa nt He a lth Pro g ra m Go a ls

Go a ls o f the Ma te rna l I nfa nt He a lth Pro g ra m  Suppo rt Me dic a id b e ne fic ia rie s to pro mo te he a lthy pre g na nc ie s, po sitive b irth o utc o me s, a nd infa nt he a lth a nd de ve lo pme nt  L o ng -te rm g o a l to re duc e infa nt mo rta lity a nd mo rb idity a mo ng the Me dic a id po pula tio n  Supple me nt me dic a l pre na ta l a nd infa nt c a re

Go a ls o f MI HP  Suppo rt the b e ne fic ia ry in a tta ining he a lth a nd we ll-b e ing b y ide ntifying a nd a ddre ssing the impa c t o f the so c ia l de te rmina nts o f he a lth  Pro mo te he a lth e q uity  Pro vide c a se ma na g e me nt a nd he a lth e duc a tio n inte rve ntio n se rvic e s, fo c using o n the mo the r-infa nt dya d  Co o rdina tio n a nd c o mmunic a tio n with prima ry c a re pro vide rs a nd Me dic a id he a lth pla ns

Ho w Ca se Ma na g e me nt Assists Ac c o mplishing Go a ls o f MI HP

MI HP a nd Ca se Ma na g e me nt  E vide nc e -b a se d va lida te d a sse ssme nt a dministe re d b y RNs a nd L SWs  F a c ilita te s the de ve lo pme nt o f a n individua lize d Pla n o f Ca re , inc o rpo ra ting :  Be ne fic ia ry's sta te d ne e ds, g o a ls, a nd re so urc e s  I nte rve ntio ns b a se d o n risk sta tus  Co mmunic a tio n a nd c o o rdina tio n with MI HP te a m, me dic a l c a re pro vide rs a nd Me dic a id he a lth pla ns  Pro fe ssio na l visits de live re d b y RNs, L SWs, RDs, a nd infa nt me nta l he a lth spe c ia lists to imple me nt inte rve ntio ns

MI HP se rvic e s inc lude :  Co o rdina ting c a re b y mo nito ring :  I mple me nta tio n o f the Pla n o f Ca re  Se rvic e s e nsuring a ppro pria te disc ipline s a nd inte rve ntio ns a re re nde re d  Appro pria te utiliza tio n o f se rvic e s  Se rvic e s whe n multiple pro vide rs a re invo lve d  Assisting b e ne fic ia ry with pro b le ma tic situa tio ns a nd ne e ds, a s the y a rise .  Mo tiva tio na l I nte rvie wing a nd c o a c hing the b e ne fic ia ry to wa rd se lf-e mpo we rme nt a nd se lf- ma na g e me nt  Ma inta ining c o mmunic a tio n with the b e ne fic ia ry/ c a re g ive r to e va lua te whe the r the Pla n o f Ca re is e ffe c tive in me e ting the b e ne fic ia ry’ s g o a ls

MI HP se rvic e s inc lude :  Assisting the b e ne fic ia ry to ide ntify:  Ne e ds  Go a ls  Re so urc e s  Stre ng ths  Ba rrie rs  F a c ilita ting c o nne c tio ns with pro vide rs o f se rvic e s a nd suppo rts; a dvo c a ting o n b e ha lf o f the b e ne fic ia ry to o b ta in se rvic e s, if ne e de d  Pro viding e duc a tio n a nd o the r se rvic e s a s indic a te d in the Pla n o f Ca re

Applying Ca se Ma na g e me nt to MI HP A Ca se Study

Asse ssme nt Co mpre he nsive Asse ssme nt o f c lie nt’ s c urre nt ne e ds thro ug h da ta g a the ring , a na lysis, a nd synthe sis o f info rma tio n. A Ca se Ma na g e r’ s re spo nsib ilitie s:  K no w a nd unde rsta nd the a sse ssme nt to o l  Re spe c t the individua l b e ing inte rvie we d  L iste n  Use Mo tiva tio na l I nte rvie wing

MI HP Asse ssme nt Pro fe ssio na l sta ff must:  K no w a nd unde rsta nd the Co mpre he nsive Asse ssme nt (risk sc re e ne r)  AL WAYS tre a t the individua l b e ing inte rvie we d re spe c tfully  L iste n  Use Mo tiva tio na l I nte rvie wing

Ca se Ma na g e me nt Pla n o f Ca re Co mpre he nsive pla n tha t inc lude s:  Sta te me nt o f pro b le ms/ ne e ds a fte r a sse ssme nt  Stra te g ie s to a ddre ss the pro b le ms/ ne e ds  Me a sure a b le g o a ls to de mo nstra te re so lutio n o f the pro b le m/ ne e d  T ime fra me  Re so urc e s a va ila b le  De sire s/ mo tiva tio n o f the c lie nt So urc e : CMSA, Sta nda rds o f Pra c tic e fo r Ca se Ma na g e me nt

MI HP Mo de l Pla n o f Ca re Co mpre he nsive pla n tha t inc lude s:  Co mpre he nsive Asse ssme nt  Risk I de ntifie r Sc o re She e t  Pla ns o f Ca re a c c o rding to ide ntifie d ne e ds  E vide nc e b a se d inte rve ntio ns a ddre ssing spe c ific risk/ ne e d  Pro g ra m mo de l time line fo r pro viding inte rve ntio ns a nd se rvic e s  Appro pria te re so urc e s b a se d  I de ntific a tio n a nd inc o rpo ra tio n o f b e ne fic ia ry’ s g o a ls/ ne e ds

Pla n o f Ca re Pla n o f Ca re is fluid with o ng o ing a sse ssme nt during a ll pro fe ssio na l visits.  Pla ns is inte nde d to g uide ho me visito r to a ssist b e ne fic ia ry in ide ntifying :  Ne e ds  Go a ls  Re so urc e s  Stre ng ths  Ba rrie rs  I t is vita l tha t the MI HP ho me visito r pla ns fo r the ne xt visit b a se d o n b e ne fic ia ry’ s c urre nt ne e ds

F a c ilita tio n o f Ca re F a c ilita tio n inc lude s:  Ca re c o o rdina tio n  Co mmunic a tio n a nd Co lla b o ra tio n  Clie nt  Clie nt’ s fa mily o r c a re g ive r,  I nvo lve d me mb e rs o f the pro fe ssio na l he a lth c a re te a m  Othe r sta ke ho lde rs  I nvo lve d o rg a niza tio ns/ a g e nc ie s  E vide nc e o f F a c ilita tio n thro ug h  Co mmunic a tio n  Do c ume nta tio n