Medical Management Guide, 2009, Version 3.0 - Tricare

More documents

Recommendations

Info

Page 64Case Management Version 3.0Medical Management Guide*May not be based on regional contract. Mosttransplant contracts occur in the civilian system. Inthe MTF, the case manager may coordinate with theMCSC on this type of referral.Additional factors that may trigger a referral to CMare:• Non-adherence to the medical treatment plan.• A need for care coordination between multipleproviders/facilities.• Complicated family dynamics that interfere withrecovery and maintenance of wellness.Case managers working in an Air Force MTF shouldcontact their Health Care Integrator (HCI) anddisease manager to coordinate efforts. Army orNavy case managers should contact their PopulationHealth department.2. Case ScreeningA beneficiary may qualify for CM if that patientrequires close collaboration and/or communicationbetween healthcare team members, due to thecomplexities of his/her condition/disease and/orsocial situation. If the beneficiary does not meetscreening criteria for CM enrollment, the casemanager contacts the original referral source tocommunicate the reasons and offer alternativeassistance, if available. Nonetheless, the casemanager may provide disposition planning andassistance to the patient and act as a referencesource for immediate, pressing issues.(Refer to CD-ROM Resource CM-5 for CMscreening criteria.)MTFs should target specific patient populations forCM based on the local CM or MM plan and policiesgoverning MCSC contracts. Case managers shouldgive priority to ADSMs. As noted in the TRICAREPolicy Manual (available at http://manuals.tricare.osd.mil/), some of the more common conditions/diagnoses that require CM in the MHS includetraumatic brain injury (TBI), burn patients, andinfants admitted to the NICU. When performing dataanalysis of utilization rates, frequent or prolongedhospitalizations and treatments (e.g., chemotherapy,pain management, use of monitoring equipmentfor uterine conditions or apnea) may be a “red flag”indicating patients who could benefit from CMservices. The utilization manager can obtain andanalyze relevant data and make referrals to CM (seeSection II, Utilization Management).3. Case SelectionIf the beneficiary meets the screening criteria, thecase manager will meet with the beneficiary andoffer him/her enrollment into CM. If the beneficiaryaccepts the offer for CM services, the casemanager will provide his/her contact informationto the beneficiary. As part of the process ofdeveloping a treatment plan, the case managershould also perform an assessment/risk appraisalof the level of severity of the beneficiary’scondition and/or the complexity of care required(see CD-ROM Resource CM-6).Case managers should also provide the beneficiaryand his/her family with an introductory letter,enrollment form, and/or marketing brochureexplaining CM (see Promoting Your Program,later in this section, and CD-ROM Resource
Medical Management GuideVersion 3.0Case ManagementPage 65CM-23). The introductory letter should explain thecircumstances in which information is released toother entities, and how and when the beneficiarywill receive written notification of the plan ofcare (refer to CD-ROM Resource CM-7 for asample introductory letter).When a beneficiary agrees to be case managed,the case manager must obtain written consentfrom either the beneficiary or his/her legal guardianprior to acting on the beneficiary’s behalf. Writtenconsent is a legal requirement that allows the casemanager to discuss and arrange the beneficiary’streatment plan with other parties. (Refer toCD-ROM Resource CM-8 for a sampleauthorization form for disclosure of medicalinformation and CD-ROM Resource CM-9 foran original informed consent form.)If the beneficiary or his/her legal guardian declinesCM services, or if the beneficiary is not acceptedinto CM, the case manager should document thedeclination or reason for non-acceptance in thebeneficiary’s outpatient medical record. The primarycare manager (PCM) and the individual who madethe initial referral should also be notified of thedecision. The beneficiary can be re-referred if his/her status or environment changes. (Refer toCD-ROM Resource CM-10 for a non-acceptanceletter and CD-ROM Resource CM-11 for aninability to contact form.)As part of the enrollment process, the case manageradds the beneficiary to the CM caseload database,which allows for efficient beneficiary tracking,continuity of care, outcome measurement, andreporting.The Six-Step Case Management ProcessAfter completing the preparatory steps ofbeneficiary identification/case finding, casescreening, and case selection, the case managerperforms the six basic steps of CM:1. Assessment2. Planning3. Implementation4. Coordination5. Monitoring6. EvaluationFig. 16 illustrates the six-step CM process.These essential steps constitute key activities thatare systematic, yet dynamic. Your individual ServiceBranch will have established timelines for how longyou have to contact a patient and to complete apatient plan of care, and for how often you mustfollow up with your patient and document theplan. For more information on the specific policiesof your Service Branch, contact your supervisor ordepartment head.6. Evaluation5. Monitoring4. Coordination3. Implementation2. Planning1. AssessmentFig. 16 — The Six-Step CM Process
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: Medical Management Guide Version 3.
Page 39: Medical Management Guide Version 3.
Page 44 and 45: Page 26Utilization 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 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
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

Create successful ePaper yourself

Delete template?

Save as template?