The CMO’s case management system emphasizes prevention, continuity of care, and coordination of care and includes the following:
Peach State has policies and procedures in place to ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• 2014 CM Program Description (entire document)
• Policy: GA.CM.08 Care Coordination / Case Management Services (entire document)
• Sample: Complex Assessment Form
• Sample: HROB Assessment Form
• Sample: Care Plan
(a) Early identification of members who have or may have special needs. Peach State has policies and procedures in place to ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
Met Not Met N/A
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Findings: Peach State demonstrated compliance through the CMO’s use of predictive modeling (Impact Pro) to identify members with special needs and the use of the health risk assessment (HRA). Case selection and assignment was prioritized by members assigned a PCP and identified with a risk score above 4.65.
Required Actions: None.
(b) Assessment of member’s risk factors. Peach State has policies and procedures in place to ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Met Not Met N/A
Findings: Peach State staff reported during the on-site interview that the HRA was available for all members to complete, and that members are encouraged to complete the HRA, but completing it was not mandatory. The case management team will also reach out telephonically to the members identified for case management to complete a general screening to determine the member’s needs.
Required Actions: None.
(c) Development of a care plan. Peach State has policies and procedures in place to ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and
Met Not Met N/A
documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Findings: A member’s care plan addresses the member’s physical, social, and behavioral health issues that have been identified during the assessment. The goals were member-centered, measurable, and achievable; however, for adults, the level of provider, caregiver, or guardian involvement in the development of the care plan was lacking.
Required Actions: The CMO should incorporate provider, family, caregiver, or guardian input into the development of the care plan.
(d) Referrals and assistance to ensure timely access to providers. Peach State has policies and procedures in place to ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Met Not Met N/A
Findings: Peach State reported during the on-site audit that members do not need prior authorization for in-network providers, but they do for out-of-network providers. Members are also encouraged to contact their PCP for a referral to an in-network provider, but this was not mandatory. A member may self-refer to a specialist without seeing his or her PCP first.
Required Actions: None.
(e) Coordination of care actively linking the member to providers, medical services, residential, social and other support services where needed.
Peach State has policies and procedures in place to ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop
Met Not Met N/A
treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Findings: Peach State reported during the on-site audit that case managers are responsible for making clinical referrals to ensure timely access, and non-clinical staff can arrange for referrals to community resources. Team members facilitate timely coordination of services though pre-certification of services if necessary, and follow up to ensure services were both provided and effective.
Required Actions: None.
(f) Monitoring. Peach State has policies and procedures in place to
ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Met Not Met N/A
Findings: Peach State provided documentation that showed a formalized monitoring process. The case file review showed that the contact frequency with the member was at an interval appropriate for the member’s needs. During the case management file review, it was noted that there was a lack of medication reconciliation by the case managers. No medication reconciliation was identified for any of the cases reviewed.
Required Actions: Case managers need to complete medication reconciliation with all members in case management. This includes creating the most accurate
list possible of all medications a member is taking—including drug name, dosage, frequency, and route—and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points.
(g) Continuity of care. Peach State has policies and procedures in place to
ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Met Not Met N/A
Findings: Peach State reported during the on-site audit that the CMO ensures member continuity of care despite a practitioner’s discontinuation of its contract with the CMO. For members who are actively receiving a course of treatment for an acute episode of chronic illness or acute behavioral health conditions, the CMO will continue treatment with the provider for up to 90 days, or through the postpartum period for members in the second or third trimester of pregnancy.
Required Actions: None.
(h) Follow-up. Peach State has policies and procedures in place to
ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
Met Not Met N/A
• Document: HROB Assessment Form
• Example: Care Plan
Findings: Peach State provided documentation that showed a formalized process for monitoring and following up with providers, members, and/or caregivers/
guardians. During the case management file review, it was noted that there was fragmentation of follow-up between physical health and behavioral health. With physical health, HSAG saw evidence of active follow-up of the member’s progress and needs. For behavioral health (BH), HSAG identified that referrals for BH services were being given, but there was no follow-up with the provider, member, or caregiver/guardian concerning the member’s utilization of services,
diagnosis, medications, and/or progress.
Required Actions: Case managers need to monitor both the member’s physical health and behavioral health progress. This will include behavioral health service utilization, diagnosis, medication reconciliation, and treatment progress.
(i) Documentation. Peach State has policies and procedures in place to
ensure case managers provide early identification of members who have or may have special needs, perform necessary assessments of member’s risk factors, develop treatment plans, develop care plans, facilitate referrals, and provide care coordination with providers and other organizations to include monitoring, follow up and documentation.
Peach State demonstrates this through the following documents:
• Document: Health Risk Assessment
• Document: HROB Assessment Form
• Example: Care Plan
Met Not Met N/A
Findings: Peach State provided examples of documentation completed in the clinical documentation system. During the case management file review, it was noted that this documentation provides a concise demonstration of interventions, education, and referrals being completed for members. The documentation also provided demonstration of provider outreach for continuity of care purposes.
Required Actions: None.
10. Case Management—Identify Members With the Greatest Need: 42 CFR 438.208(c); Contract 4.11.9.3
Peach State focuses on early identification of members with a complex severe illness which require intensive management and extensive amounts of resources in order to regain optimal health or improved functionality.
Met Not Met N/A
The CMO makes a special effort to identify members who have the greatest need for case management, including those who have catastrophic or other high-cost or high-risk conditions, including pregnant women under 21, high risk pregnancies, and infants and toddlers with established risk for
developmental delay.
Peach State ensures high risk, catastrophic, pregnant women under 21, high risk pregnancy, and infants and toddlers are identified early. Peach State demonstrates this through the following documents:
• 2014 CM Program Description, (entire document)
• Policy: GA.CM.08 Care Coordination / Case Management Services, Pages 3-6, 24-25
• Reference: GA.CM.8 Automatic Referral List, Attachment A (entire document)
• Policy: GA.CM.07 Start Smart for Your Baby (entire document)
• Member Handbook, Pages 19-27
• Provider Handbook, Pages 38-43
Findings: During the case management file review, it was noted that members identified for case management were typically pulled from a trigger list. The case file review did not show evidence of cases being identified through Impact Pro despite some members with serious conditions.
Required Actions: The CMO should review its predictive modeling algorithm to determine if members with special health care needs are being identified as early as possible and being referred for care management services.