Medical Management Guide, 2009, Version 3.0 - Tricare

More documents

Recommendations

Info

Page 82Case Management Version 3.0Medical Management Guidewould need to be obtained for infusion therapyservices. Communication among home healthcompanies, the coordinating case manager, andthe ordering provider further serves to reconcilethe treatment plan with the service order.3. Formulation. Discharge planning can be verysimple or highly complex. It is best accomplishedusing an interdisciplinary approach to determinethe best plan for each patient. In Active Dutycases, the patient’s Command may have inputon the discharge plan.4. Implementation. The case manager will revieweach patient’s discharge plan with the patient/caregiver prior to discharge and enter theappropriate documentation in the patient’smedical record.5. Monitoring. Monitoring the quality andeffectiveness of the discharge planning processis a cumulative effort. The importance of timelyfeedback from providers, patients/caregivers,case managers, and discharge planners cannotbe overstated.Prior to discharge, the case manager mayrecommend a home assessment to anticipate allenvironmental needs in conducting a safe discharge.This is an important intervention, especially whenthe patient is coping with a severe disability thatmay involve complex mechanical assistance. Ifthe discharge is likely to be complicated, the casemanager may convene a pre-discharge planningmeeting to verify that both family members andhome care providers understand their roles, and thateveryone shares similar expectations and goals.The discharge plan should be family-centered andshould take into consideration:• Patient/family preferences.• Consideration of existing DoD/VA memorandaof understanding (MOUs).• TRICARE benefit parameters.• Qualifications for entitlement programs (e.g.,ECHO).• Previous experience with existing providers andfacilities.• Most appropriate provider/facility for thepatient.• Location of facility and providers, and theirability to meet patient/family needs.• Understanding of patient-specific goals.• The parent Command and PatientAdministration departments (if the patient is anADSM).• Impact on medical readiness and the DisabilityEvaluation System (DES) process.Barriers to effective and timely discharge planninginclude delays in completing discharge details,duplication of services, lack of patient focus, andinvolvement of available patient transport resources.Some root problems in discharge planning includelack of patient involvement/understanding of thedischarge plan, poor coordination/communicationwith the patient/family and/or caregiver(s), andpoor communication within medical providers.The patient must agree with the discharge plan tosupport maximum adherence.
Medical Management GuideVersion 3.0Case ManagementPage 83Care CoordinationCare coordination is a function of CM that involvesassisting individuals with complex circumstances (i.e.,circumstances that place them at risk for diminishedindependence) in gaining access to needed medical,social, educational, financial, and other servicesacross various organizations and providers. Theprocess coordinates the continuum of care forbeneficiaries whose needs exceed routine dischargeplanning but do not meet the requirements for longtermCM.Examples of patients who might benefit from carecoordination include those who:• Are at risk for a failed inpatient discharge plan.• Have special needs (e.g., children, the elderly,newly diagnosed diabetics, individuals withcatastrophic injuries).• Require extensive short-term coordination andmanagement.• Have greater-than-average needs identifiedduring pre-discharge planning that do not meetthe criteria for formal CM.• Have needs that require medium-intensityinteraction with the case manager.• Have acute, immediate needs that are notexpected to require continuous treatment inthe long term (e.g., patients receiving a hipreplacement).AccreditationWhile MCSC CM programs may be accreditedby URAC, the contract is not contingent onaccreditation. For more information on URAC’s mostcurrent CM program accreditation guidelines, go tohttp://www.urac.org/.The CMSA provides program accreditationinformation at http://www.cmsa.org/.Promoting Your ProgramWhether a CM program is being established or isalready in place, the key to sustaining the programis to optimize the department through marketing.Once your marketing strategy is established, you willwant to build a caseload (see Caseload, earlier inthis section). Here, the key decision is to expand theservices offered to other areas or sustain existingservices. CD-ROM Resource CM-23 provides asample CM marketing brochure. You may also wantto take advantage of promotional opportunitiesin Nurses Week, Social Workers Week, and CaseManagers Week to market your CM services.See Section I, Medical Management Essentials,Program Sustainment, for more details onpromoting MM programs.LEGISLATIVE GUIDANCE SPECIFICTO INTEGRATING PHYSICAL ANDPSYCHOLOGICAL REHABILITATIONTitle XVI of the National Defense AuthorizationAct (NDAA) of 2008, Wounded WarriorMatters, Section 1611, addresses thechallenges associated with caring for wounded,ill, and injured ADSMs and their families (seeExecutive Summary, CD-ROM Resource ES-4).In this section of the law, the NDAA outlines specificscreening, referral, and management requirementsfor identifying the signs of post-traumatic stressdisorder (PTSD), TBI, and BH conditions such assubstance abuse and suicide risk. The law placesparticular emphasis on identifying and reactingto these conditions in response to the increase of
Page 2 and 3:
Instructions:When accessing this Gu
Page 6:
Page viExecutive SummaryVersion 3.0
Page 9 and 10:
Medical Management Guide Version 3.
Page 11 and 12:
Page 13 and 14:
Page 15:
Page 20 and 21:
Page Medical Management Essentials
Page 22:
Page Medical Management Essentials
Page 25 and 26:
Medical Management GuideVersion 3.0
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39:
Page 44 and 45:
Page 26Utilization Management Versi
Page 46 and 47:
Page 48 and 49:
Page 50 and 51: Page 32Utilization Management Versi
Page 66 and 67: Fig. 11 (cont.) - MTF Review and Ap
Page 72: Page 54Utilization Management Versi
Page 76 and 77: Page 58Case Management Version 3.0M
Page 118 and 119: Page 100Case Management Version 3.0
Page 123 and 124: Medical Management GuideVersion 3.0
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
show all

Medical Management Guide, 2009, Version 3.0 - Tricare

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?