Money Follows the Person/
Pathways to Community Living
Care Management Processes
Revised 2/6/2015
Goals of Care Management
Improve individual/family/caregiver’s participation in healthcare decisions
and management.
Improve individual/family/caregiver’s abilities to self-manage health
conditions, medication adherence and participation in health promotion
activities.
Assist individual/family/caregiver in proactive monitoring, evaluating and
problem solving.
Improve collaboration among/between individual/family/caregiver,
providers and care managers.
Improve the coordination and continuity of care across the continuum of
care.
Improve individual/family/caregiver’s health status, satisfaction and
quality of life.
Improve the delivery of cost effective care in the least restrictive
environment.
2
Care Management Definition
Care Management is a person centered team based approach
(individual/family/caregiver, care manager, primary care provider/psychiatrist)
which integrates health care and social supports. It is based on a
comprehensive multi-disciplinary assessment that identifies and prioritizes
goals, strengths, problems/risks and barriers to care. A collaborative
comprehensive plan of care is developed and implemented, proactively
monitored and evaluated, following evidence-based guidelines and standards
of care which promotes self-management of health conditions, medication
management, health promotion activities, and assures that identified providers,
services and supports are meeting the needs of the individual/family/caregiver.
Transitions in care are managed with timely follow-up, facilitation of
communication between providers, and individual/family/caregiver with
adjustments to the plan of care.
(Schraeder, 2012)
3
Community
Services
Substance Abuse
Home
Transportation
Pharmacy
Home Health
Person/
Family
Person
Centered
Behavioral Health
Provider
(PCP,
psychiatrist)
Support System
Hospital
(Schraeder, 2012)
CM/CMN
Long Term Care
Finance
Specialty Care
4
Roles of a Care Manager
Coach/Educate
Empower
Facilitate
Support
Advocate
Negotiate
Assess
Plan
Implement
Monitor
Evaluate
Collaborate
Coordinate
Manage
Document
(Schraeder, 2012)
5
Care Management Activities
Assess health status, goals, strengths, problems/risks, barriers to care,
needs and self management abilities of each individual.
Develop and implement with individual/family/caregiver/providers a
comprehensive care plan based upon evidenced-based guidelines and
standards of care.
Coach, teach and empower individual/family/caregiver to learn and develop
abilities to self-manage: health conditions, medications, red flags, and
identified problems/risks.
Coordinate and follow-up with formal and informal service providers.
Collaborate with other disciplines and professions regarding the
individual/family/caregiver’s plan of care.
Support individual/family/caregiver to implement plan of care, report
challenges/successes, and changes in status.
6
Care Management Activities
Facilitate communication of pertinent information between providers and with
individual/family/caregiver while tracking health status over time with early
communication of changes.
Advocate for the individual/family to ensure the correct level and type of care
and services are received.
Negotiate with healthcare system and payor sources to obtain necessary
services.
Manage transitions of care.
Monitor and evaluate effectiveness of the plan of care, teach
individual/family/caregiver how to evaluate the effectiveness of their plan of
care and revise plan of care to reflect changes in individual’s health status,
psychosocial needs, and self-management abilities.
Document individual/family/caregiver and provider contacts
(Schraeder, 2012)
.
7
Case Study
Ms. Paula Johnson is a 60 year-old Caucasian female, 5’2” and 235 pounds, with a
BMI of 43, which is considered heavily overweight. She was admitted to Oak Nut
nursing facility 3 years ago after an accident that resulted in a spinal fracture and
cord injury at T4-5. She uses a wheelchair for mobility. Her other diagnoses include
Type II Diabetes Mellitus (DM), Coronary Artery Disease (CAD) with a previous
Myocardial Infarction (MI), and Hypertension (HTN). Her primary language is English
and she can read and write. She is of the Catholic faith and likes to attend mass at
least once a week. She is not in need of a guardian and her emergency contact
person is her sister who lives 4 hours away. She is divorced. She does not have any
legal documents in place (no POA or living will). Paula has a 9th grade education and
has worked in dry-cleaning intermittently. She was arrested once for shoplifting and
on probation for 2 years afterwards. This happened about 25 years ago and she has
not been in legal trouble since. She had a bank account in the past, but had difficulty
remembering to pay her bills. Her current income is SSDI at $652.85 a month. She is
on Medicaid and has no idea if she would qualify for Medicare. She lived
independently in the community before her accident.
8
Collaborative Care Management
Engage Referral
Conduct Comprehensive Assessment
Case Contact:
Engage
Referral
Develop Individualized Plan of Care
Implement Plan of Care
Provide Self-Management
Transition:
Monitor &
Evaluate Plan of
Care
Pre-Transition:
Conduct
Comprehensive
Assessment
Person/Family
Centered
Provide Medication
Management
Reinforce Health Promotion
Coordinate Care/Services
Provide Transitional Care
Transition:
Implement Plan
of Care
Pre-Transition:
Develop
Individualized
Plan of Care
Perform Critical Incident
Review
Facilitate communication
across continuum
Monitor & Evaluate Plan of Care
(Schraeder, 2012)
9
Case Contact: Engage Referral
10
Identification & Referrals
Potential MFP individuals are primarily
identified through the following mechanisms:
a)
b)
c)
d)
e)
f)
g)
Local or Regional Ombudsman
Self-Referral from individuals or families
Nursing facility or provider staff
Other agencies
HFS online MFP/Pathways’ referral form
SODC closures (DDD specific)
Class action lawsuits
11
MFP/Pathways Referral Process



Submission of online referrals starts the MFP process.
If there are no issues with the referral data, it will be
routed directly to the agency based on routing rules.
 If there are issues (e.g. data discrepancies, no RIN),
the referral will be processed by HFS and manually
distributed.
Once a referral is passed to an agency for follow-up, it
becomes a “Case” in the WebApp.
 Cases are linked to a individual – meaning a
individual can have multiple cases but all are linked
together in CRM/WebApp.
12
MFP/Pathways Referral Process



Initial contacts cannot be entered in CRM without a
referral.
New referrals from HFS need to be followed up on within
10 days of receiving the referral.
Referrals can be sent back to HFS if they need follow up
from a different state agency.
Referrals are entered here:
https://mfp.hfs.illinois.gov/mfpreferral.aspx
13
Conducting Case (First) Contact







Determine if the referral has a legal guardian.
Determine if there is a family member/significant
other who is actively involved in their care.
Maintain privacy and confidentiality when meeting
with the referral.
Inform referral of the reason for your visit.
Describe your role, the MFP/Pathways program
and the type of housing, services and supports
available to them in the community. For more
information, visit http://www.mfp.illinois.gov/
Provide referral and/or guardian with a copy of the
MFP/Pathways brochure and your contact
information.
An MFP first contact is considered a face-to-face
meeting unless the referral’s guardian is located
outside the local area.
14
Complete Case Contacts
The First contact date is shown
here.
Click “+” to add a new
Case Contact.
All Case contacts are listed here.
Click the “Name” link to view a contact.
15
Case Contacts: Not in the Facility

If you find out from the institutional care setting staff that
the individual you are trying to contact has
 become
 has
deceased or
moved out of the facility…
Complete a case contact to document this outcome.
This closes the loop on the referral.
16
Informed Consent

Completed when individual indicates he or she would like
to enroll and plans to transition to the community through
MFP/Pathways.

Two original copies must be signed and dated by the
individual (or proxy or guardian) prior to transition in order
for the individual’s transition to be valid for MFP.
 One
copy is given to individual/guardian
 One
copy is kept for TC’s file
17
Informed Consent = MFP Enrollment

A individual is enrolled if, and only if, the individual
(and/or guardian) has agreed to participate in MFP by
signing the Informed Consent document.

The date of the individual’s signature on the Informed
Consent is the date of enrollment. (There is no more
Form B).

If the individual or guardian no longer wishes to sign the
informed consent, document this by completing a new
case contact since the individual is no longer
“Considering MFP”.
18
Advance to Informed Consent
Stage
vance
to Informed
Consent
1. After you
have documented
that a potential
individual is
Considering MFP, you can advance to the next stage of
Stage
the transition planning process.
2.
Click the “Next Stage” button in CRM to advance to the
Informed Consent stage (move the blue flag!).
19
Release of Information




At the time of receiving informed consent, determine if
the individual has any family/friends/ significant others
that they want to be part of the transition planning
process.
If someone is identified, have the individual sign a
release of information to permit you to speak with that
person(s).
Also, obtain a release of information for formal and/or
informal providers involved in the individual’s care.
This release of information can be uploaded as an
attachment in CRM.
20
Case Note
21
Pre-Transition
22
Comprehensive Assessment

Assessment is the first essential function of the care
management process.

Assessment is an organized, multidimensional process by
which the care manager, through interaction with the
individual, significant others, guardian, healthcare
providers, review of facility record, agency assessments,
and Medicaid claims data, collects and analyzes in-depth
information on domains including demographics; individual’s
goals, likes or dislikes; cognition/comprehension; diagnoses;
substance use; utilization; medications; health; social history;
functional status; safety issues, and; self-management skills.
23
Assessment: Key Sources







Individual
Institutional record
Nursing facility staff
Family members, friends, and/or guardian
Health and service providers
Agency assessments
Medicaid claims summary
24
Institutional Record








Face/Diagnosis Sheet
Medication List
Progress Notes
MDS
Nursing Assessments
Labs
Diagnostic Procedure Results
Other Service Provider Reports
25
Medicaid Claims Summary
Institutional Visits by Day
 Diagnosis Groupings
 Prescription Groupings
 Procedure Groupings
 Facility Services Received
 Provider Frequency
 Institutional Admissions
 Institutional Discharges

26
Example of Institutional Visits
27
Example of Diagnosis Groupings
28
Example of Institutional
Admissions & Discharges
29
Face Sheet (Form F)




Includes social and financial history, major diagnoses,
sensory needs/impairments, individual goals
Required to be completed before transition
Add information as needed both pre- and post-transition
Click the “Plus (+)” to add a Face Sheet
30
Medications and Supplies (Form G)





Required to be completed before transition
Must have prescriptions ready for when individual
transitions
UIC clinical staff, pharmacists, institutional care
setting staff can assist when needed
Provide the individual with a copy of his/her
Medications and Supplies List
Add/Update information as needed both pre- and
post-transition by updating existing list
TIP: Review the list during monthly home visits.
Update it in CRM and print a new list for individual
with each medication change.
31
Poll Question
Identify key sources for gathering
information for your assessment.
 Answer options

 Individual
 Institutional
record
 Nursing facility staff
 Family members, friends, and/or guardian
 Medicaid claims summary
32
Risk Assessment/Inventory
(Forms H&I)

Completely updated questions and format
 80
 10
questions
domains

Required to be completed prior to transition and
must be operational on first day of transition

Identifies potential risks and plans to address
known risks

Should include everything the TC will be doing to
structure and maintain a safe transition
33
Risk Assessment/Inventory
(Forms H&I)
 Physical Health
 Behavioral & Emotional Health
 Substance Abuse
 Self-Harm or Harm to Others
 Cognition
 Medication, Laboratory, & Utilization
 Functional
 Environment
 Interpersonal & Social Supports
 Engagement, Self-Management & Recovery
34
Begin Risk Assessment/Inventory
1. Click the “+”
2. Click Save.
3. Click on Risk Assessment
35
Complete Risk Assessment/Inventory
1. Select a
Domain
2. Check the box if this Question
is a Risk for the individual.
3. Describe why it is a risk
Note: If question is not a risk,
click Save and continue to next
question. Always click save
or Update after each question.
You can close the window and
return to it later.
4. Complete pre- and posttransition plan.
5. Click Save and continue to
complete remaining questions and
domains until progress bar shows
100% complete.
36
Risk Stratification Criteria

Persons are identified as high risk transitions who have
(based on recent literature):
 Coronary Artery Disease (CAD), Chronic Obstructive Pulmonary Disease
(COPD), Congestive Heart Failure (CHF) and hospitalized within the past
12 months prior to transition.
 Acute Myocardial Infarction (AMI), Dementia, Arthritis, Atrial Fibrillation,
Cancer, Renal Failure, Diabetes, Osteoporosis, Serious Mental Illness,
Cerebrovascular Accident (CVA), Substance Abuse, and hospitalized
twice within the past 24 months prior to transition.

Persons are identified from MFP data review as high risk
for reinstitutionalization/mortality who have:

Diabetes, medication risks, require additional supports to live in
the community, pre-transition emergency room visit/hospitalization
within 12 months of transition, and post-transition hospitalization.
37
Risk Assessment/Inventory Process




Identify risks in each risk domain
Discuss risks with individual or guardian
Prioritize risks requiring immediate action
Develop plan with individual or guardian to manage risks




Focus on techniques that will increase individual’s knowledge of
his/her chronic conditions, enhance self management strategies,
and coordinate services across health care settings while
identifying and addressing barriers and gaps in care.
Incorporate evidence based practice research into plan.
Review plan at least monthly
Revise plan based on changes to individual’s level of
care
38
Poll Question


Identify risks and related domains for Paula.
Answer Options





Functional: Difficulty managing finances.
Environmental: Requires adaptive equipment for mobility.
Physical Health: Multiple chronic diseases.
Physical Health: Requires a special diet.
Interpersonal and Social Supports: Lack of peer support.
39
Mitigation Plan (Form J)







New format – no additional data entry required.
Required to be completed before transition and after
Risk Inventory has been completed.
Printable report available in CRM. TC reviews completed
Risk Assessment/Inventory. Edit as needed.
Involve individual/guardian to achieve the best possible
outcome and keep it person centered.
Document agreement and have individual/guardian sign
the mitigation plan.
Upload signed copy to CRM and provide
individual/guardian with a copy.
Evaluate effectiveness of plan during follow-up visits.
40
Mitigation Planning
Transition Coordinator activities:






Involve the individual and/or caregiver in every step of mitigation
plan development.
Prioritize risks based on the level of each risk, the individual’s
readiness to change and the individual’s ability to self manage
identified problem areas.
Establish goals and activities based upon the individual’s
preferences.
Provide individual and/or caregiver with guidelines for selfmanagement techniques.
Create a “notebook” where the individual and caregivers can
keep guides, logs, notes or questions to discuss with various
providers or CM.
Determine contact schedule and who will conduct the coaching,
supporting, collaborating, monitoring, and evaluating.
41
Example Mitigation Plan
42
Example Mitigation Plan
43
24 Hour Back-Up Plan (Form K)






New format – no longer one page (includes Personal
Resource List – Form L).
Completion required prior to transition and must be
operational on first day of transition.
Back-up providers should be identified for all critical
services.
Individual and/or primary caregiver(s) should be
educated on how to use the back-up plan in different
scenarios.
Printable version available in CRM.
Provide individual and/or caregiver(s) with a copy.
44
Quality of Life Survey

Federal requirement. If not completed prior to transition, then
transition will not count for MFP.

Must be completed prior to transition scanned and uploaded to the
CRM or faxed to UIC.

Complete one week to 30 days prior to transition, no earlier.

If individual refuses, contact Farris Watson at
Farris.Watson@illinois.gov for more information.

Second QoL Survey: conducted by UIC College of Nursing at
“First Follow-Up” (about 11-12 months post-transition OR by
DDD)

Third QoL Survey: conducted by UIC College of Nursing at
“Second Follow-Up” (about 2 years post-transition OR by DDD)
45
UIC Case Review






All pre-transition documentation should be completed prior to
requesting a case review.
A case review is completed by UIC prior to transition and sent to all
parties involved in the individual’s transition. Including Managed
Care Organization (MCO) staff
A case review call is scheduled and occurs within 60 days prior to
the individual transitioning. (If individual does not transition within 60
days after the completion of case review, then another case review
will be scheduled.)
The case review will cover Medicaid claims data, risk inventory and
mitigation plan, and risk status and risk categorization.
A list of clinical questions and action plan items will be included in
the case review.
This is the time to ask questions regarding the individual’s
diagnoses, medications, or other necessary supports and services.
46
Poll Question


What mitigation strategies would be in your service plan
to address the identified risk of limited social support with
an individual diagnosed with Major Depressive Disorder.
Answer options
 Arrange and monitor caregiver services.
 Provide contact numbers to peer support groups in
the community.
 Arrange transportation as needed.
 Arrange weekly counseling session with a mental
health provider.
47
Transition
48
Transition (Form C)




Completed on the day of transition or within 2
business days post-transition
Starts MFP 365 day clock of eligibility
Records date of transition
Records housing information, new address,
county and appropriate waiver, state plan and
demonstration services.
49
Implementation of Mitigation Plan:
Day of Transition
Transition Coordinator activities:
 Be present on the day of transition both at the nursing facility and at
the individual’s new residence.
 Obtain agreed upon medication supply and/or prescriptions from the
nursing facility.
 Ensure all medical supplies and furniture were delivered to individual’s
new residence.
 Ensure all utilities and the emergency medical response unit are in
working condition.
 Review medication chart and the 24-hour back-up plan with individual.
 Arrange for personal assistant, homemaker, family member/friend,
and/or home health nurse to be present at the new residence.
50
Case Note
51
Post-Transition
52
Implementation of Mitigation Plan:
First Week After Transition
Transition Coordinator activities:
 Conduct at least one face-to-face visit within the first week after
transition.
 Determine if there are any outstanding or new issues and/or changes
to the individual’s condition.
 Determine if individual has enough medications and is taking her
medications as prescribed.
 Inquire about the individual’s satisfaction with caregiver services.
 Review dates of upcoming provider appointments.
 Determine follow-up schedule with individual. (Intense monitoring is
typically required the first eight weeks after transition and again after
an emergency room visit or hospitalization.)
53
Implementation of Mitigation Plan:
Ongoing
Transition Coordinator activities:
 Coordinate and ensure individual is receiving
necessary services such as home health care for
diabetes management.
 Collaborate with community and health care
providers.
 Monitor caregiver’s ability to safely assist individual
in transferring and managing ADLs/IADLs.
 Coach individual on the development of self
management skills and educate on symptom
identification (e.g., checking and logging blood
sugar readings).
 Establish medication and nutritional goals and
monitor progress.
 Re-assess individual’s needs, risks and strengths
after any health changes.
54
Monitoring & Evaluation
Monitoring
 Assess individual’s status and responding quickly to physiological,
behavioral or other changes.
 Conduct visits on a regular basis.
 Address individual’s ongoing needs, identifies new needs, and
follows up on progress towards care plan goals.
Evaluation
 Conduct on a regular basis.
 Evaluate and adjust mitigation plan to reflect changes to individual’s
status and ability to self-managed.
 Identify successful and unsuccessful interventions.
 Involve individual and/or family members in revising care plan to
meet his/her changing needs.
(Schraeder & Shelton, 2011)
55
Monitor & Evaluate
Transition Coordinator activities:



Assess for changes in health
status and/or medications.
Assess for utilization of
emergency room, hospital,
and/or physician visits.
Provide resources, equipment
and services:





Were ordered services delivered?
Are services appropriate and
meeting individual’s needs?
What gaps in services exist?
Are there any new needs?
Is durable medical equipment in
working order? Inspect and
confirm it is being used by
individual appropriately.


Monitor safety and social
support.
Assess housing situation.

Is housing appropriate and
meeting needs?
 Does individual enjoy living in her
new residence?
 Does individual feel safe and
secure?


Assess overall satisfaction
with community living.
Monitor development of selfmanagement strategies (i.e.,
medication management).
56
Update Documentation






Face Sheet
 Add any new diagnoses.
Medication List
 Add new medications and/or remove medication discontinued by
medical provider(s). Provide individual with a printed copy of the
medication list.
Risk Assessment/Inventory
 Determine if there are any changes to risk inventory domains.
Mitigation Plan
 Determine if new goals and/or strategies are needed.
24-Hour Back-Up
 Review contacts on back-up plan and add new contacts as
needed.
Notes
 Document notes with every individual contact.
 Document notes throughout the entire transition process.
57
UIC 30-day Post-Transition Follow-Up



TC and UIC clinical consultant will arrange a time around thirty days
after transition to discuss individual’s adjustment to community
living. Collaborating agencies, including MCO staff, are invited.
TC will provide an update on the individual’s first month in the
community.
Discussion points may include:
 Status of action plan items established in transition plan,
 Status of follow-up with medical providers,
 Changes to medication regimen,
 Identification of critical incidents,
 Discuss unforeseen issues/risks,
 Discuss strengths, goals, likes/dislikes, etc.
58
Poll Question
Name other activities you would conduct
during your follow-up visits with Paula.
 Answer options





Determine if Paula has enough medications and diabetic
supplies.
Discuss level of satisfaction with personal care assistants.
Create goals and discuss progress in meeting them.
Discuss any changes from provider appointments.
59
Post-Transition Update (Form E)

Is completed
 when
a new risk assessment/inventory is completed
that requires a change in the Mitigation Plan
 when there is a change in residence address
 when there is a change in waiver or demonstration
services
 when there are calls for emergency back-up (e.g., If a
TC finds a individual had to use their back-up plan for
transportation, caregiver, meal services, or
emergency ambulance transport).
60
Disenrollment/Withdrawal
(Form D)


Occurs anytime a individual is no longer enrolled
 A individual is no longer eligible or interested in
transitioning.
 Once a transitioned individual has been
re-institutionalized for 30 days.
Occurs only if an Informed Consent has been signed
61
Re-transition after Re-institutionalization

If a individual was re-institutionalized for greater than 30
days after transition and before his/her MFP
graduation date, then he/she is eligible to re-transition
with MFP and use the remainder of the days left on
his/her MFP clock.
62
Re-Enrollment: Post 365 Days

If an individual completes 365 days in the
community and has been re-institutionalized in a
qualified institution (e.g., nursing facility) for 90
days or more, then TC can start a new record for
the individual, complete the enrollment and
transition process again.
63
In Summary

Transition coordinators have a vital
and complex role in success of
individuals transitioning to the
community from institutional care
settings.
64
Questions
65
References
See handout: Care Management Coordination bibliography
66