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

• 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

• 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

• 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

• 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

• 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

• 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

F a c ilita tio n o f Ca re

Suc c e ssful fa c ilita tio n is suppo rte d b y:

 Pro a c tive c lie nt-c e nte re d re la tio nships  T

ra nsfe r o r tra nsitio n o f c lie nts to a ppro pria te pro vide r/ re so urc e

 Do c ume nta tio n re fle c tive o f c o lla b o ra tio n

a nd tra nspa re nt c o mmunic a tio n

 Use o f pla n o f c a re , ta rg e t g o a ls a nd c lie nt’ s

ne e ds/ pre fe re nc e s

 Adhe re nc e to c lie nt priva c y a nd

c o nfide ntia lity

MI HP F a c ilita tio n o f Ca re

Ca re Co o rdina tio n

Arra ng ing a ppro pria te a nd ne e de d re fe rra ls Co mmunic a tio n with a ll individua ls,

• rg a niza tio ns, institutio ns e tc . invo lve d in

a c c e ssing ne e de d c a re / re fe rra ls

Do c ume nta tio n

E nsuring a ppro pria te c a re pro visio n

Utilizing ne e de d MI

HP disc ipline s

Co ntinuo us mo nito ring o f the Pla n o f Ca re He a lth pla n re so urc e s T

ra nsitio n fro m MI HP

MI HP F a c ilita tio n o f Ca re

Co mmunic a tio n a nd Co lla b o ra tio n with Be ne fic ia ry

Mo tiva tio na l inte rvie wing L

iste ning

I

de ntifying a nd b uilding o n stre ng ths

Advo c a c y

Ne c e ssa ry c o mmunic a tio n a nd c o lla b o ra tio n with:

Othe r MI

HP disc ipline s fo r o ptima l de live ry o f MI HP se rvic e s

Me dic a l pro vide r(s) Me dic a id He a lth Pla n

E duc a tio n, E va lua tio n, Advo c a c y a nd Co st E ffe c tive ne ss

 E

duc a tio n

 T

e a c hing

 I

nfo rming

 E

mpo we ring

 E

va lua tio n

 Clie nt ne e ds  Clie nt se rvic e s  Re so urc e s

 Advo c a c y

 Optio ns a nd se rvic e s fo r c lie nt  Ac c e ss to re so urc e s  Co st-e ffe c tive o utc o me s

 Pro mo ting the mo st e ffe c tive a nd e ffic ie nt use

• f he a lth c a re se rvic e s a nd fina nc ia l re so urc e s

MI HP E duc a tio n, E va lua tio n, Advo c a c y a nd Co st E ffe c tive ne ss

 E

duc a tio n

T

e a c hing e xa mple s

He a lth e duc a tio n I

nde pe nde nc e

Sa fe ty F

a mily pla nning

I

mmuniza tio ns

I

nfo rming

Re so urc e s a va ila b le

E

mpo we ring

Using stre ng ths a nd re c o g nizing b a rrie rs to

e mpo we r b e ne fic ia ry

MI HP E duc a tio n, E va lua tio n, Advo c a c y a nd Co st E ffe c tive ne ss

 E

va lua tio n

Be ne fic ia ry ne e ds

Do e s a no the r disc ipline ne e d to visit? Ha s a sudde n ne e d o c c ur?

Be ne fic ia ry se rvic e s

Do mo re o r le ss visits ne e d to b e ma de ? I

s a he a lth pla n b e ne fit a ppro pria te ?

Re so urc e s

Wa s the b e ne fic ia ry a b le to a c c e ss the re so urc e ? I

f no t, wha t is the ne xt ste p?

MI HP E duc a tio n, E va lua tio n, Advo c a c y a nd Co st E ffe c tive ne ss

 Advo c a c y

On b e ha lf o f b e ne fic ia rie s yo u se rve with:

MDHHS Me dic a l pro vide r He a lth pla n Co mmunity Re so urc e re fe rra l

With the b e ne fic ia rie s yo ur se rve re g a rding :

Ne e de d re so urc e s He a lth c a re

 Co st-e ffe c tive o utc o me s

Pro mo ting the mo st e ffe c tive a nd e ffic ie nt use o f

he a lth c a re se rvic e s a nd fina nc ia l re so urc e s

Pro viding MI

HP se rvic e s ne e de d, no mo re o r le ss

Qua lity I mpro ve me nt

Ca se Ma na g e rs a nd Qua lity I mpro ve me nt

Ca se ma na g e rs a re in a prime po sitio n in the a sse ssme nt a nd imple me nta tio n o f Qua lity I mpro ve me nt thro ug h:

 F

a c ilita tio n a nd c o o rdina tio n o f se rvic e s

 Mo nito ring c lie nt pro g re ss a nd o utc o me s  Unde rsta nding the “b ig pic ture ” o f the c lie nt’ s sto ry  K

no wle dg e o f pla n o f c a re a nd de sire d o utc o me s

T he c a se ma na g e r c a n impro ve the q ua lity o f the c lie nt e xpe rie nc e

Ca se Ma na g e rs a nd Qua lity I mpro ve me nt in MI HP

 Asse ss a g e nc y a nd c a re de live ry pro c e sse s a nd

• utc o me s

 Cha rt re vie w  Utilize o b je c tive da ta  So lic it input fro m b e ne fic ia rie s re g a rding the ir c a re

 Mo nito r tre nds

 Pro fe ssio na l sta ff  E

duc a tio na l Ma te ria l

 Be ne fic ia ry do sa g e o f se rvic e s

 Pro mo te c o mplia nc e with the pro g ra m

 Po lic y  Ope ra tio n Ma nua l  Pla ns o f Ca re

Ple a se Write Que stio ns o n the Ca rds o n the T a b le

Contac t Infor mation

Suze tte Bur kitt- We sole k, RN, BSN

Ac ting Pro g ra m Co o rdina to r a nd Qua lity I mpro ve me nt Co o rdina to r fo r the Ma te rna l I nfa nt He a lth Pro g ra m Mic hig a n De pa rtme nt o f He a lth a nd Huma n Se rvic e s Divisio n o f Ma te rna l a nd I nfa nt He a lth L a nsing , Mic hig a n 48909 BurkittWe so le kS@ mic hig a n.g o v

So urc e s

 Ca se Ma na g e me nt So c ie ty o f Ame ric a (CMSA). (re vise d, 2016).

Sta nda rds o f Pra c tic e fo r Ca se Ma na g e me nt. L ittle Ro c k, Arka nsa s: CMSA

 Na tio na l Co mmitte e fo r Qua lity Assura nc e , (2016). NCQA 2016

He a lth Pla n Sta nda rds a nd Guide line s. Wa shing to n, DC

 De pa rtme nt o f Huma n Se rvic e s Ne w So uth Wa le s, (Ve rsio n 2.0,

Ma rc h 2010) Ca se Ma na g e me nt Pra c tic e Guide , 7 Pha se s o f Ca se Ma na g e me nt. Ne w So uth Wa le s

 Co mmissio n fo r Ca se Ma na g e r Ce rtific a tio n (CCMC), a c c e sse d

Oc to b e r 1, 2017, a t https:/ / c c mc e rtific a tio n.o rg