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TSWF Case Management Pediatric AIM Form Training January Jan-Apr - - PowerPoint PPT Presentation
TSWF Case Management Pediatric AIM Form Training January Jan-Apr - - PowerPoint PPT Presentation
TSWF Case Management Pediatric AIM Form Training January Jan-Apr 2019 Form Version These slides were not updated during the May-Aug 2020 release but are still relevant Medically Ready ForceReady Medical Force Dis isclaimer Content
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Objectives
CM/CM Peds Training Objective: Identify the clinical workflows, assessments and tools available in the TSWF CM/CM Peds form CM/CM Peds Learning Objectives: At the conclusion of today’s activity, the participant will be able to:
- Verbalize key elements found on the General Assessment tab such as Pain Assessment,
ROS, Surgeries/Hospitalizations, and Patient History
- Understand the use of other tabs on the form (i.e. Functional Assessment; Pysch/Social
Assessment; Health Habits/Wellness etc.)
- Describe the purpose and use of the CM Care Plan tab
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Why Use TSWF CM Pediatric AIM IM Form?
- Provides comprehensive identification of patient care needs
(historical and current) to primary and interdisciplinary care teams
- Supports dedicated care management requirements through:
- Standardized and improved evidence-based documentation
- Detection of care coordination requirements
- Reduced variance and fragmentation of care management
activities
- Easy access to references for clinical decision-making
- Improved continuity of care and healthcare outcomes
- CM Reference links
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Why Use TSWF CM Pediatric AIM IM Form?
- Critical Tool in Complex CM Core Position Requirements:
- Address total needs of patient and family on a regular and
recurring basis
- Improve collaboration with interdisciplinary teams to improve
- utcomes
- ‘Proactive management’ to support and address
comprehensive health needs and transition of care requirements, minimize fragmentation, and promote patient safety, quality of care, and cost-effective outcomes
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Demonstration of f Form
The following slides will walk through each tab
- f the Case Management Pediatric AIM form.
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Resources
Form version, links to MilSuite, TSWF Navigator, TSWF Resources, and Change Log are listed at the top
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Demographics Tab
Screening for CM screening patients Specify whether or not patient is a candidate
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Demographics Tab (c (cont.)
To type text in an empty field, place cursor near colon/prepositioned text and begin typing
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Mil ilitary His istory Tab
Documentation to reflect AD member history: Since this is the child’s record, emphasize that this describes the parent(s) and how the child may be impacted during deployments/TDYs.
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General Assessment Tab
Emphasizes a full system review: Enhanced care planning and needs identification Comprehensive system review includes Dental
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General Assessment Tab (c (cont.)
Additional documentation to assess needs specific to:
- Dietary
- Behavioral Health
- Episodic care mgmt
(Continuity of Care Issue should be investigated)
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General Assessment Tab
Medical l Con
- ndit
itions
Comprehensive review by body system: Allows for individualized identification of specified needs
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General Assessment Tab
Behavioral l Healt lth Con
- nditions
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Full review of medication:
- Evaluate understanding and
reason for prescribed meds
General Assessment Tab
Additional Medication Do Documentation
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Functional Assessment Tab
Specify ADL capabilities ‘Requiring Assistance’ box: CMs documentation required in the event the child is dependent
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Functional Assessment Tab (c (cont.)
Assess Living arrangements:
- Ensure ongoing medical care support
is available in the event the primary home of record changes, to ensure continuity of care is uninterrupted.
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Functional Assessment Tab
DM DME
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Functional Assessment Tab
DM DME (c (cont.)
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Psych/Soc Assessment Tab
Psych/Social Tab:
- Opportunity to assess
additional family or Behavioral Health support, if needed
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Psych/Soc Assessment Tab (c (cont.)
If patient is a student, document this as occupation, grade, type of schooling; daycare, homeschool, public, private, etc.
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Psych/Soc Assessment Tab
Environmental l Con
- ncerns
Comprehensive Environmental assessment should be completed and routinely reassessed to identify potential ‘triggers’ that could exacerbate existing conditions.
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Health Habits/Wellness/Misc Tab
Health Habits Assessment:
- Assess patient’s needs
- Coordinate any gaps with immunizations
with the PCMH team and document
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Health Habits/Wellness/Misc Tab
Alc lcohol
Beneficiaries who consume alcohol should complete an Audit C. The Case Manager should coordinate results back to PCMH Team. Enter AUDIT-C date and score here
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Health Habits/Wellness/Misc Tab Tobacco
Assess for alcohol or tobacco use. If identified, documentation should include:
- Coordination with the Primary Care Provider/Team
- Resources/Benefits available to eligible
beneficiaries and follow-up
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Care Team Tab
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Care Team Tab
Sp Special l Se Services/Referrals ls
Comprehensive evaluation of specialized services is available. Utilize the ‘Other’ section to identify additional services, if needed.
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CM Care Pla lan Tab
Recommend using this format The CM workflow is to address each problem with a separate care plan. The narrative and updates quickly reach the 2000 word limit. It is not recommend to add multiple plans to the same field.
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CM Care Pla lan Tab
A care plan outline can be pasted here (place cursor in top left corner and paste). Be sure to answer care plan review question when pertinent. Answer diagnosis/prognosis question if applicable. If answer is ‘no,’ you may need to address as a barrier to care.
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CM Care Pla lan Tab
(A (Army Additional Do Documentation)
Required for Army WTU CM Documentation (Information applies to Service Member)
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Defi finitions Tab
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TSWF Resource Material
The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/
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