Case Management Policy and Guidance

Angela Braithwood, RN, BSNSenior QA Analyst, Case Management

ServicesSkyline Ultd.

Objectives

• Army Case Management Overview• Policy and Guidance • Training and Education Requirements• CMSA and Certification

Army Case Management Model

• DoD– Focus on education and training of CM’s– Inclusion Criteria for MND

• Army – WTU’s and MMC– Based on CMSA Standards– Core competencies– AC-centric: No reserve component model

• National Guard – Varies by State– No official guidance from NGB

Warrior Transition Command

• Where we all started– Initial concept 1994– Initial development 2004– Formalization to WTC in 2005 CPL Kendra Coleman recovers

at Walter Reed National Military Medical Center after losing her left leg in Afghanistan

Applicable Policies for Case Managers

• Case Management Society of America Standards of Practice for Case Management (2010)

• CMSA Core Curriculum for Case Management, 2nd Edition. Suzanne K. Powell & Hussein A. Tahan. Philadelphia: Lippincott, 2008

• Department of Defense TRICARE Management Activity Medical Management Guide Version 3.0

• DTM 08-033, Interim Guidance for Clinical Case Management for the Wounded, Ill, and Injured Service Member in the Military Health System

• DoDi 6025.20, Medical Management• MEDCOM Soldier Medical Readiness Campaign 2011-2016• HQDA EXORD 118-07, Healing Warriors• MEDCOM OPORD 07-55, MEDCOM Implementation of the Army Medical Action Plan

(AMAP)• MEDCOM OPORD 11-20, Patient Centered Medical Home• MEDCOM OPORD 10-66, Medical Management Centers• Comprehensive Transition Plan Guidance

DoDi 6025.20 Medical Management (2006)

• Establishes Medical Management Care Model within the MHS– Utilization Management– Case Management– Disease Management

• Integration and coordination of services– Quality, completeness, and adequacy of total

health care• Outcome Management

DTM 08-33 (July 2012)

• Interim Guidance for Clinical Case Management for the Wounded, Ill, and Injured Service Member in the Military Health System

• Originally released Aug 2009• All-service and component requirements• Basic education, certification, and training• Performance Measures• Documentation/Coding

CMSA Standards of Practice

• The Professional Organization of Army Case Management

TRICARE MMG

• Military Health System Guide to Case Management

MEDCOM OPORD 13-25 Nursing Case Management Guidance

• Consolidation of references• Across all components• 5 lines of effort

– CM ID– Training/Education– Performance standards– Quality outcomes/measurement– Strategic communication

Army National Guard Case Management

• Goal – Reduce Medically Not Ready population to maximize number of Soldiers available for mobilization/deployment– PHA/SRP/SRC Support– LOD/IDES Preparation

• Remote Care – Telephonic Case Management– Electronic Database Systems

MEDCOM Soldier Medical Readiness Campaign 2011-2016

• Strategic Level Medical Readiness Plan

• Population Health• ID, Mgt, Health

Promotion• Performance

Measures• Commo

MEDCOM OPORD 10-66, Medical Management Centers

• Closest to what we do at the AC level• Manages MNR Population• Collaboration with Units• Expands use to the RC

Triad of Care

ARNG

OSS

G-1

SM

UNIT

WTU

PCM

NCM

SM

SQD LDR

• AC based on active, clinical CM

• RC based on non-clinical CM

ARNG Case Management Environment

Training and Education

• MHS Learn– Case Management Track– Miliman Ambulatory Care

• Core Curriculum• Army CM Course

– Essentials of Case Management (fee)

MHS Learn Case Management Training

Competency AssessmentCase Manager Core Competencies Individual Assessment

Name: ___________________________________ Orientation Start Date: _____________ Completion Date: _____________ Purpose: To standardize the knowledge, skills, and attitudes within the covered professional specialty for all case managers: military, civilian, contractor, and volunteer. Instructions: Pre-Assessment-the case manager will rate each knowledge, skill, or attitude (KSA) from 1 (novice) to 5 (expert) in each box. Following orientation or training, the case manager and preceptor will collaboratively provide a post-assessment.

Competency (Knowledge, Skill, Attitude)

Assessment Method Comments References

(see Appendix A) Pre Post

Foundational/Generic Competencies (consistent for all RNs

CRITICAL THINKING: Demonstrates common nursing skills, knowledge, and attitudes for safe and effective independent nursing practice

Maintains current: RN License; BCLS Certification

Promotes teamwork in a positive manner. Uses ethical, professional, and courteous communication with providers & other departments with no substantiated negative reports. Uses clear concise communication.

Displays values of a DA and DOD employee: Dedications, Integrity, Loyalty to the mission and the unit, Respect, Selfless Service, Honor, and Personal Courage

Personal Accountability: Arrives to work on time and departs as scheduled unless prior approval is obtained. Articulates annual leave policy. Uses Sick Leave as intended by policy. Calls appropriate supervisor when late or sick. Appearance - Clean professional dress. Has hospital name badge and CAC. Completes all assigned tasks by suspense date and time, to include support forms, audits, peer reviews, documentation in databases, memorandums, request for information, and any additional tasks given.

Knowledgeable of American Nurses Association standards of practice for nursing and Case Management Society of America standards of practice for case managers

Demonstrates effective conflict management Demonstrates effective change management

CMSA and Certification

• Army prefers Certified Nurse Case Managers.– AC has CCM course for ANC and DA– No RC course/track yet– Fee-based course for all others

Questions?

Backup/Reference Slides

Comprehensive Transition Plan Guidance

• WTU Action Plan for Soldiers• Two Tracks

– Remain in the Army– Transition out of the Army

• Closely tied with MTF’s and PCMH

HQDA EXORD 118-07, Healing Warriors

• Part of the Army Medical Action Plan (AMAP)• Involvement of all Commands (IMCOM, MEDCOM, etc)• WTU’s more widespread (one at each MTF)

– Triad of Care• Soldier and Family Assistance Centers (non-medical)• FRAGOS

– 1: Administrative changes to staff visits, add more specific tasks to Chiefs of Staff, adjust focus

– 2: SFAC setup– 3: Refining WTU screening and entrance criteria– 4: Reserve Component Remote WTU focus

MEDCOM OPORD 07-55, MEDCOM Implementation of the Army Medical Action

Plan (AMAP)• Incorporates HQDA EXORD 118-07 tasks to

MEDCOM• Tasks RMC’s with AMAP deadlines• Streamlines Soldier and Family transition• Sets up TDA and Unit criteria

MEDCOM OPORD 11-20, Patient Centered Medical Home

• MHS Primary Care Model– Part of Access to Care Campaign (2008)

• 100% direct care enrollees in a PCMH NLT FY 2015• Utilization Management• Based on NCQA Standards for PCMH

The Bible

AR 40-501 Standards of Medical Fitness

27 27

MRNCO -assist SM w

records/profiles - BN monthly report

- hand off to CM

Case Manager(CM) -reviews case

- assigns to

Care Coordinator (CC)

CC continues to - assist SM

Case meeting #1 CMD/SS/G1 and CM

Case meeting #2CMD/SS/G1 and CM

CC continues to - assist SM

Case meeting #3CMD/SS/G1 and CM

MRDPNot reached

MRDP ?May get

ONE TIME temp prof extension

per SS

Temp profile written

(issue found by self report, PHA, PDHA,

PDHRA)

0 MO NLT 3 MO NLT 6 MO NLT 9 MO NLT 12 MO

- coordinate w

CM/MRNCO as

needed

- coordinate w

CM/MRNCO as needed

Each case meeting assures: 1) temp profile updated as warranted 2) eval for AD orders for medical care (WTU/RCMC) 3) eval for MMA assignment (option for CMD)

MMPS

Recording Procedures

28

Appropriate profile is issued

Appropriate profile is issued

Temporary Profile is issued

A Permanent 2 Profile is issued

A Permanent 3 Profile is issued

Medical condition is non-duty related

Medical condition is duty related

Soldier is referred to MAR2

Soldier recovers

Soldier is referred to MEB

PEB - Fit Soldier continues with physical disability

processing

Soldier receives Administrative

Discharge

Soldier returns to

duty

PEB - Fit PEB - unfit

Appropriate disability is awarded

Soldier is retained with a change in MOS

LegendMedical ActionMilitary Personnel ActionActive Component ActionMAR2 – MOS Administrative Retention ReviewMEB – Medical Evaluation BoardPEB – Physical Evaluation Board

Soldier meets Retention Standards

Soldier does not meet Retention Standards

A provider determines that a soldier has a medical limiting condition

The Physical Disability Evaluation System

The Physical Performance Evaluation System

Soldier is issued a permanent profile

Soldier is retained in MOS

Soldier is retained with a trial duty

PEB - Unfit

Soldier elects a non-duty PEB