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Ryan WhiteMedical CaseManagementPractice anddocumentation review1Originally presented March 28, 2013Slides 59-61 amended March 29, 2013

2Important reminders

3Client records are legaldocuments Records may (and have been in the past)subpoenaedBe careful about putting too much detail in casenotes that may open your agency to liabilityAll documentation must be objective andprofessional No happy faces, no subjective statements unlessquoting a clientDate of document must match signatures No pre- or post-dating documents to technicallymeet deadlines

4Client records are legaldocuments Neveridentify someone else’s status, mentalhealth conditions, or substance abuse in yourclient’s record Do not assume that writing “partner” isdeidentifying -- you likely have a release to thatpartner with his or her name on it in the recordas well Remember:Clients have a right to review theirrecords at any time per HIPAA

5Face-to-face contacts Theannual assessment must be completedface-to-face for both Ryan White andMaineCare Semiannual certifications must be completedface-to-face for Ryan White You cannot complete the document over thephone and then have the client sign next timehe or she comes into the officeYou cannot mail to client to sign

6ADAP ADAPis the payer of last resort Clients must apply to MaineCare ADAP coverage is based on clients’ eligibility If a client is eligible for MaineCare but lostit for failing to recertify, client only receivesADAP coverage wrapping around typicalMaineCare coverage (i.e. ADAP pays 3 or 10 copay) If client has no insurance and then gets anykind of insurance, notify ADAP immediately

7CAREWare issues

8Services Ifyou log a care plan and/orassessment and/or semiannualcertification service, you do NOT needto log “1200 Referral and monitoringservice from care plan” for the samecontact (unless you work at FPC) Do not forget to log “1100 ClientCertification” or you will not be able torun reports to show when nextcertification is due

9Annual review Discrepancybetween annual reviewinformation (required to be reported tothe feds) in CAREWare and info onsemiannual certification in chart If housing, insurance, medical care, orincome information changes, youmust update CAREWare

10Household size and income “Household”is defined as the client and anylegal household members (legally marriedspouse, dependent children, dependentadults) More on this later Incomefor all members of the householdmust be included Ryan White definitions of household may bedifferent from MaineCare and HOPWA.Always report the Ryan White information inCAREWare.

11Labs CMsare required to enter CD4sand Viral Loads in CAREWarewhen they are collected forthe semiannual certification

12CAREWare upgrade Thisis the buggiest upgrade we’ve everinstalled Known bugs: Searching by drop downs (e.g. CM assigned)doesn’t workYou can’t sort any of the search terms that don’tfilter correctly in the find listProvider Notes ARE NOT restricted to Providers(think of them as being the same as CommonNotes)Some issues with permissions and custom fields

13CAREWare upgrade Incomeinfo may look a bit strange,because of the way information rolls over

14CAREWare upgrade Anyother questions about theupgrade? If you come across a problem,please send a detailed emailabout it to be forwarded to theHelp Desk

15Semiannual certificationUpdates to form

16Now two processes New client intake 1-page form completed once at intake Focused on demographic data that do notusually change No service in CAREWareSemiannual certification 5-page form completed every six months Enter service # 1100 Client Certification

17

18Updates to semiannualcertification form Someelements rearranged for flow Labs now highlighted to remind CMs toenter in CAREWare Expanded insurance section

19

20Documentation review

21Results from Dec chart reviewsTotal number of records reviewed:Section 1: Client Identification and EligibilityTotal number of records with Section 1 complete:Section 2: Semi-Annual CertificationTotal number of records with Section 2 complete:Section 3: AssessmentTotal number of records with Section 3 complete:Section 4: Consent FormsTotal number of records with Section 4 complete:Section 5: Care PlanTotal number of records with Section 5 complete:Section 6: Case Notes and MonitoringTotal number of records with Section 6 complete:Section 7: Client Record DocumentationTotal number of records with Section 7 complete:Section 8: Discharge SummaryTotal number of records with Section 8 complete:Total number of records with all sections %1838% ** Contractual expectation: 90% of client records audited during the contract year are complete

22Improvement Continuingto have high completionrates in certain areas Client identification & eligibility (96%) Assessment (98%) Discharge (98%) Ratings in care plan section showingprogressive improvement Currently at 67%

23Problem areasClient record documentation Down to 69% (from 84% in June) Income verification Consent forms Case notes & monitoring Care plan

24Client record documentation

25Forms must be completed Ifa client identifies no needs in anarea, the zeroes still need to befilled out on the acuity scale If you use a second page of a careplan only for signatures, the blankboxes above must have a linedrawn through them

26Forms must be completed

27Forms must be completed

28Forms must be completed

29Forms must be completed

30Why be so picky? From Maine’s Notary Guide:Blanks may affect the validity of a documentNever use “white out” products to alter adocument. If language needs to be altered,the signer should cross out or line through thelanguage and initial all altered areas in thedocument. Althoughforms are not notarized, they arelegal documents and must be held to thesame standard

31Income verification

32Continuing issues Requiredfor entire legal household If client has a legal spouse, thespouse’s income must bedocumented as well Required to be verified every sixmonths Document must be less than oneyear old

33What’s a “legal spouse”? Same-sexspouses previouslymarried in other states Same-sex spouses recently marriedin Maine Separated spouses who are not yetdivorced

34Income verification Ifclient fails to provide incomeverification within 30 days, he orshe must be discharged from RyanWhite case management perHRSA requirements

35Consent forms

36Releases for MaineCare Youdo not need a release to MaineCareto discuss services they pay for that youprovide e.g. “Did you see John Doe on Thursday?” YouDO need a release to MaineCare todiscuss: a client’s coverage and eligibilitythe client’s adherence to medication/medpickupsthe client’s use of the ER

37Other issues Makesure release forms arecompletely filled out Draw a line through blank areas,just like any other document Fill in all dates Clearly indicate the intent of therelease

38Case notes & monitoring

39Recurring issue Leavingparts of the case notetemplate blank Fillin blank areas, just like anyother document Ifno referrals made or no followup necessary, write “none”

40Most common issue Insufficientstatement of howthe contact supports treatmentadherence Lengthier does not mean moreaccurate

41Examples of good treatmentadherence statements transition to new PCPViral load increasingfollow up for PCP blood workclient experiencing difficulty getting prescriptionsthrough new mail-order pharmacyCoordination and monitoring of housing needs helpsclient stay focused on adherence to treatment.Coordination of insurance enables client to access medswithout interruption.Addressing barriers to care enables client to maintainfocus on adherence to treatment.Stable living situation allows client to attend to HIV selfcaregood dental hygiene decreases risk of opportunisticinfection

42More examples good vision allows clients to read medicine bottlesTo go over goals to ensure client is getting enoughservices to stay adherent to meds.maintaining a good diet helps with keeping clientadherent to meds.to obtain stable housing for medicationadherence, to obtain job so that client is able toget some income to afford basic necessities andto see his provider to get medications to stayhealthyContinued connection to PCP enhances healthoutcomes

43More examples Adequatefood/nutrition enhances healthoutcomes Access to dental care enhances overallhealth. Transportation to attend medicalappointment Good mental health/social supports improvesoverall wellbeing, and decreases depressionand despair, which improves treatmentadherence Accessing/ maintaining benefits ensures thatclient is able to access services and care

44Care plans

45Care plan issues1.2.3.Care plan goals do not match needsidentified on assessmentCare plans in chart not reviewed in personor by phone and signed by CM Usually relates to client who wasdischarged (see next slide)Client has not achieved at least 4 shortterm goals Usually due to goals not being specificenough or issue on next slide

46Review care plans at discharge Whendischarging a client,review the care plan to showthe status of goals at the timeof discharge

47Care plan goals Mustcorrespond to an identified needon the assessment If a new need arises, use theAssessment Update form to document Make sure it is clear from the narrativein the section why this is a need Althoughthis will not keep a chart frompassing a review, it is a common issuenoted in state audits

48Problems with goals Manycare plans with exact samegoals carried over for a year ormore Many care plans with exact samegoals for all clients on a caseload Care plan goals not specificenough Care plan goals not achievable

49SMART Goal WritingFor client care plans and agency action plans

50SMART Goals Specific Measurable Achievable Relevant Time-bound

51Specific Aspecific goal has a muchgreater chance of beingaccomplished than a generalgoal. Who is doing the activity? What is the action/activity?

52Measurable Establishconcrete criteria formeasuring progress toward theattainment of each goal you set. How much change is expected? Will there be an increase ordecrease? Can you measure it?

53Achievable Canit be done? Can you accomplish it in theprescribed timeframe? Do you have the necessaryresources?

54Relevant Doesthe action relate to whatyou want to accomplish? Is it important and meaningful? Does it relate to broader, longterm goals for theclient/program/organization?

55Time-bound Whatis the timeline for change? When will this be accomplished?

56Action Planning Everyagency continues to fall belowperformance targets for completerecords Every agency fell below theperformance target for hours per FTEper week for at least one quarter thisyear Most fell below the performancetarget every quarter

57Hours per FTE per week Since2008, the Ryan White Part BProgram has been tracking hours perFTE per week Expectation is that MCMs will spendhalf of their RW-funded time on directclient service The other half is for paperwork,CAREWare entry, meetings, etc.

58Why? Itis not unreasonable to expect that half of acase manager’s RW-funded time be spent ondirect service If this is not happening, there are importantquestions to ask: Is the CM spending time on non-RW activities?Is the CM not accurately reporting RW time?Should the budget be adjusted to pay for lessdirect RW time?

59How we calculate it Allclient time logged in CAREWare for theperiod Jan. 1-Dec. 31, 2012 Travel time to and from clientappointments logged in CAREWare forthe period Jan. 1-Dec. 31, 2012 Divided by 44* weeks (to get hours perweek) Hours per week divided by FTE incontracts (to get percent of FTE)* Reduced from 52 to account for 12 holidays and 28 vacation/sick days

CM% 231%1331%1426%1522%1612%60 5out of 16 RW-fundedmedical case managers meetthe standard for calendaryear 2012 Median 38% That means, in a regular 40-hourwork week, 15 hours were spent meeting with clients by phoneor in person having collateral contact onbehalf of clients driving to and from clientappointments