Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 66Case Management Version 3.0Medical Management GuideThe six steps of CM are described in more detailbelow.decision. If a CM case is opened for the patient, thenext step is to develop a plan of care.1. Assessment2. PlanningAssessment is a systematic, ongoing activity thatinvolves collecting comprehensive information abouta patient’s situation, including all relevant sources(military and civilian) to identify individual needs.This includes speaking with the patient, caregivers (ifappropriate), and healthcare providers — especiallythe PCM. Fig. 17 describes categories of assessment.According to the NCQA (July 2007), case managersneed to address the following areas pertaining totheir patients:• Current health status, including conditionspecificissues and co-morbidities• Clinical history, including medications• Activities of daily living (ADLs)• Caregiver resources• Available benefits• Mental health status• Advanced directives• Cultural and linguistic needs, preferences, orlimitations• Financial considerationsBecause the assessment process may require thecase manager to make multiple contacts, it cantake several days to complete an assessment. Oncethe assessment is complete and problems havebeen identified, determination is made whetherCM criteria have been met and whether to open aCM case. If the decision is not to open the patientto CM, the patient is provided with appropriateresources and the referring party is notified of thePlanning involves determining specific objectives,goals, and actions designed to meet the patient’sneeds as identified during assessment. Once thepatient is accepted into CM, a plan of care isdeveloped. The purpose of the plan is to:• Address problems.• Set short- and long-term goals.• Identify barriers to reaching the stated goals.• Identify actions that can be taken (i.e.,interventions) to resolve any barriers to achievingthose goals.Problems may include:• Lack of patient access to appropriate specialistsor community resources.• An inadequate patient support system.• Inappropriate pain management.Goals may include:• Short-term goals — e.g., patient access toappropriate specialists or community resources.• Long-term goals — e.g., the patient’s ability toeffectively self-manage pain.A time frame is assigned for meeting each goal.It is important to keep the following considerationsin mind:• CMSA standards of practice state thatmeasurable goals must be established. Goalsthat promote cost-effective, quality outcomesmust be included in the plan of care and createdin collaboration with the patient and family.
Medical Management GuideVersion 3.0Case ManagementPage 67Assessment SubjectDemographicInformationMedical HistoryVocational InformationHealth Status/Systems ReviewCurrent/ProjectedResource UtilizationPsychological StatusCommunity/SocialSupportHealth Risk AssessmentHome/EnvironmentAssessmentCategories of AssessmentDescription• Name, social security number (SSN)• Service branch• Cultural considerations• Financial class (e.g., TRICARE, other health insurance, other benefits)• List of treating physicians, specialties, addresses, telephone numbers• Spiritual needs• Advanced directives/living will/power of attorney• Ancillary services• Pharmacology/use of pharmacy services• Education• Impact of health on work status• Occupation• Age-specific considerations• Health status perception• Learning abilities/comprehension• Community/workplace reintegration• Custodial care needs (activities of daily living)• Durable medical equipment (DME) requirements• Home environment/living arrangements• Medical/functional/disability/rehabilitation status• Beneficiary’s diagnosis/prognosis, short/long-term goals• Rehabilitation potential• Skilled and less-than-skilled nursing needs (hrs/day, days/week, daily visits, intermittentvisits)• Beneficiary’s/family’s emotional status• Beneficiary’s mental status• Compliance issues• Substance abuse issues• Understanding/acceptance of current problem• Age-specific considerations• Assessment of interrelationships between family members• Beneficiary/family propensity for support• Caregiver support system• Cultural considerations, including language barriers• Family members’ perception of their care/support role(s)• Marital status• Need for community resources• Spiritual support• Support system (beneficiary, caregiver, community, faith-based)• Clinical practice guideline (CPG) screening questions• Clinical preventive services• Fall risk• Beneficiary’s living arrangements• Presence of primary caregiverFig. 17 — Categories of Assessment
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