Attachment J.24 - Case Management & Utilization Management SOP.pdf

Case Management and Utilization Management May 2022

Case Management and Utilization Management

Published May 2022

Controlled Unclassified Information

Background Case management refers to evaluation and advocacy of a member’s comprehensive healthcare needs through communication and available resources that promote patient safety, quality of care, and cost-effective outcomes.1

The Clinical Centers of Excellence (CCE) shall provide a comprehensive case management program, including clinical and non-clinical services, that is appropriate for member needs and acuity levels to facilitate effective resource coordination throughout the continuum of care.

Purpose and Scope The purpose of this document is to provide guidance to the CCE contractor on their Case

Management (CM) and Utilization Management (UM) programs for responders and survivors located within the New York (NY) metropolitan area and enrolled in their assigned CCE.

The CCE shall understand the clinical, social, and administrative needs of its member population and how they relate to the World Trade Center (WTC) Health Program’s limited-care model. The CCE shall facilitate care coordination to support a smooth continuum of care across various levels of service intensity. The CCE shall assess active members for case management service needs as clinically indicated through member outreach and medical monitoring. Case

Managers shall address the unique health care needs of individual members and improve member satisfaction with the Program.

Process and Procedure – Case Management CM Model Team Structure

1. Upon contract award, the CCE shall provide details of their CM model team structure, which must include, but is not limited to, the following:

a. Clinical staff consisting of Registered Nurses and Social Workers with prior CM experience. The teams shall include backgrounds within the following areas:

i. Medical/surgical/oncology/transplant

ii. Behavioral/mental health

iii. Palliative/end-of-life care

iv. Discharge planning

v. Chronic illness/disease management

b. Non-clinical staff (such as Care Coordinators) who are integrated with clinical staff to assist with responsibilities such as:

i. Scheduling of member appointments, follow-ups, authorizations, or coordination of phone calls

ii. Documenting of member files

1 See CMSA “What is a Case Manager?” at https://cmsa.org/who-we-are/what-is-a-case-manager/ https://cmsa.org/who-we-are/what-is-a-case-manager/

2022 CM CCE Guidance

iii. Administering Initial Health Questionnaires

iv. Performing administrative support

c. The process for assigning a member to a specific CM team and transitioning a member to another CM team, whether due to medical necessity, member preference, or strategic necessity.

Care Coordination

2. The CCE shall facilitate care coordination to support a smooth continuum of clinical and non-clinical care across various levels of all member needs.

3. Members with less intensive or intermittent case management needs still require care coordination to facilitate their treatment or plan of care. Such members may be managed by a non-clinical staff member; however, any changes in member acuity requiring a clinical or licensed professional should be referred to the appropriate staff member (such as nurse, CM, SW, etc.) to assess and address those specific needs.

Case Management Coverage

4. The CCE must provide CM services to WTC Health Program members in all regions of the NY metropolitan area.

a. RNs are to hold licenses based on their member’s states of residence for conducting telephonic CM services or outreach according to the Case

Management Society of America (CMSA) standards of practice.2

5. CM services include coordination of medical benefits for members, such as:

a. Initial Health Evaluations (IHE)

b. Annual Monitoring Exams

c. Prescription Services

d. Cancer Screening

e. Case Management and Care Coordination (RN and SW)

f. Durable Medical Equipment (DME)

g. Diagnostic and Treatment Services (may require prior authorization)

h. Inpatient Care

i. Physical Therapy

6. CM services include the coordination member services, such as:

a. Certification

b. Benefits Counseling, including local social services

c. Scheduling

Case Management Assessment

7. The CCE shall assess all members for potential CM needs. The initial assessment shall occur at enrollment and then on an annual basis (or more frequently if appropriate).

Should a member requiring CM services opt to seek treatment outside of the WTC Provider Network with their private insurance, they shall continue to receive CM oversight based on their assessed needs. The assessment shall include:

a. Clinical status, diagnoses, comorbidities

b. Psychosocial status (to include available support systems as applicable)

2 See CMSA ”Multi-State Licensure” at https://cmsa.org/multi-state-licensure/ https://cmsa.org/multi-state-licensure/

c. Functional/cognitive status

d. Cultural needs

e. Nutritional/medication needs

f. Barriers to accessing care

8. The CCE shall assign acuity levels to all members requiring CM services. The acuity criteria shall align with those established by the Program. The CCE shall document the acuity levels within the CM notes in the member files and update as member needs change.

Criteria for Assigning Acuity Levels

9. The criteria for assigning acuity levels should be used in conjunction with clinical judgement. It is the responsibility of the CM to apply clinical judgment to ensure member needs are being met regardless of acuity level. Members may not meet all requirements in the respective category to qualify for that level of CM. Members may need CM intervention more or less frequently depending upon individual needs.

a. Level 0 (New)

i. For members that are newly assigned to CM who have not yet had their initial assessment completed and whose needs are unknown

b. Level 1 (Low or Supportive acuity)

i. Member is clinically stable

ii. CM outreach is required at least every 6-12 months

iii. Member is compliant with treatment plan

iv. Member can manage medication independently or with minimal support

v. Minimal coordination of medical services is required

c. Level 2 (Moderate or Progressive acuity)

i. Member is clinically stable

ii. Member may be moderately ill or have intermittent clinical instability

iii. CM outreach is required at least every 3-5 months

iv. Member may be compliant with treatment plan but have barriers to accessing care

v. Member has occasional barriers to medication adherence and requires intermittent medication management

vi. Moderate coordination of medical services is required with occasional member or family/caregiver contact

d. Level 3 (High or Intensive acuity) (See Intensive Case Management section)

i. Member may be clinically unstable, severely ill, or declining

ii. CM outreach is required frequently, at least weekly/bi-weekly but no less than once every 1-2 months

iii. Member is unable to comply with treatment plan without frequent oversight

iv. Member is unable to comply with their medication regimen without structured support

v. Frequent coordination of services is required with frequent member or family/caregiver contact

Post-discharge Outreach

10. The CM team shall implement a process in which any member, regardless of case management status, discharged from a facility following an inpatient admission (acute or post-acute) shall receive a post-discharge outreach call from a case manager. The CM shall conduct an assessment to determine if the member has any gaps in care, change in status, or overall needs that require an update to the member’s plan of care and/or treatment plan. During the post-discharge outreach, the CM shall assess the member’s current acuity level and confirm or revise as necessary. This shall coincide with the development and implementation of the Utilization Management process outlined below.

Intensive Case Management (ICM)

The Program views ICM as a value-added service provided under the leadership of a qualified professional who assists in the planning, coordination, monitoring, and evaluation of benefits and clinical services to match a member’s Program benefits and clinical requirements. The emphasis is on quality of care, continuity of services, care integration, and cost-effectiveness to optimize clinical support for vulnerable members with complex care needs.3 Not all members require ICM. The CCE shall taper off ICM services as a member’s ICM needs dissipate.

11. A Plan of Care (POC) is required for all members receiving ICM services. It must be easily identified within the CM files of the member medical record and updated as member needs change. The POC shall include:

a. Member needs and barriers to care

b. Member goals

c. Implementation plan to reach goals

d. Evaluation of outcomes

12. The ICM Operations Plan shall address each of the following requirements:

a. Process and criteria the CCE will use to identify active members who are eligible for ICM. The process will describe the evaluation protocol, linking needs identified through clinical and benefits counseling, and how the protocol will coordinate with monitoring or treatment components. Examples of eligibility criteria include, but are not limited to, significant health or safety risk due to problems identified with ability for self-management and adherence to challenging health regimens, post-acute care transition, instability leading to repeated emergency, or crisis-intervention visits.

b. Process and protocol leading to a documented POC, goal tracking, and periodic

(timely) reassessment of POC for members receiving ICM services. The POC can be integrated into the member medical record or case management administrative system and must be accessible for audit. The POC shall include each of the following key elements:

i. Specific individual care needs and barriers to care and self-management

ii. Prioritization of care needs and forecasted timeline to re-evaluate progress

iii. Interventions or actions (education, coordination, and consultation) needed to meet the care needs, and

iv. Evaluation of outcomes

c. Staffing plan and roles describing use of an ICM team approach that is cost-effective in terms of staff mix (clinical and administrative) and tasks required.

i. Professional qualifications and case management training for case managers (Registered Nurse, Licensed Clinical or Medical Social Worker) to manage the ICM service plan for each member receiving such

3 See CMSA “Standards of Practice for Case Management” at https://www.abqaurp.org/DOCS/2016%20CM%20standards%20of%20practice.pdf https://www.abqaurp.org/DOCS/2016%20CM%20standards%20of%20practice.pdf services. Care Coordinators (allied health professional or other equivalent medical experience) shall be responsible for coordinating care for members with largely administrative needs.

d. Criteria for downgrading service intensity and transitioning off ICM services. For example:

i. Member is clinically stable and/or can follow an effective outpatient plan and maintain functions of daily living

ii. Member requests to be withdrawn from ICM services

iii. Member has not responded to reasonable attempts to contact (such as no response to three phone attempts and a final outreach letter providing two weeks to respond).

iv. After member has died and after short-term grief counseling to immediate family (no more than 90 days).

e. Reports on ICM operations are due monthly and semi-annually.

f. Flow of care procedures, including prior authorization and care coordination for

Program benefits (such as conditions certified). All rendering and billing providers who see the member as a result of referrals must follow prior authorization procedures and be registered with the Program prior to billing (in non-emergency situations). The CCE shall maintain all service summary reports. Case management shall manage referrals to in-network providers for all members.

g. Process and tools (such as certifications, prior authorizations, claims, and medical summary reports) that enable the ICM team to verify that treatment is within the scope of a member’s benefit plan.

h. Medical quality assurance and member satisfaction with services. Access to member medical records for quality review purposes is required upon request by

WTC Health Program either in person or remotely, as applicable.

i. A system/process to deal with coordinating care transition, appropriate levels of care (including all levels of inpatient acute, post-acute, and outpatient services), emergency/high-risk members, including, but not limited to, multiple hospital readmissions, psychiatric emergencies, emergency discharge planning, emergent psychosocial issues, and other such issues.

j. A system/process for member transfer to another CCE or the Nationwide

Provider Network (NPN) contractor that actively addresses the POC.

Process and Procedure – Utilization Management Utilization Management (UM) refers to evaluation of the medical necessity, appropriateness, and efficiency of healthcare services in the WTC Health Program.

Level 2 Prior Authorization (PA2)

1. The CCE shall outline a plan for review of treatment to ensure services are authorized based on medical necessity as related to the members’ certified condition. This is applicable to any service requiring a PA2 including, but not limited to, inpatient hospitalizations.

2. When a member has been identified as having been discharged from an acute or post-acute inpatient facility, a CM shall conduct a post-discharge outreach as noted above.

Utilization Management Plan

3. The CCE will provide a UM plan to include the following elements as related to member’s WTC-related certified condition(s):

a. Review of authorizations for medical necessity (prior authorization/prospective reviews and retrospective authorizations) including, but not limited to, inpatient hospitalizations as related to member’s WTC certified condition(s)

b. Access to clinical information and medical records

c. Post-discharge outreach in coordination when the CM has identified a member has been discharged from an acute or post-acute inpatient facility

Roles and Responsibilities

Role Responsibility

Care Coordinator Non-clinical team members to provide clerical and administrative support to members and CM Team.

Clinical Center of Excellence

(CCE)

A medical center under contract with the WTC Health Program to provide WTC-related health services to members.

CM Team Staff members of the CCE which are designated to this team and will include clinical staff (RN Case Managers and Social Workers) and non-clinical staff (such as Care Coordinators)

Intake Team Designated staff members responsible for monitoring notification of inpatient admissions, verifying member enrollment, and communicating to the UM Review team

Intensive Case Management (ICM) Team

Any member of the CM Team assisting with coordination and facilitation of care for members engaged in ICM. (e.g., RN, SW, Care Coordinator).

NPN Contractor A nationwide network of healthcare providers under contract with the Program to provide WTC-related care for members who live outside the NY metropolitan area

Physician Reviewer Physicians required for second-level review when nurse is unable to render a medical necessity decision.

Registered Nurse (RN) Case Manager

Assess, plan, implement, and evaluate member care to facilitate member needs throughout the continuum of care.

Responder Workers or volunteers who provided rescue, recovery, debris cleanup, and related support services on or in the aftermath of the September 11, 2001 attacks for certain amounts of time during the period between September 11, 2001 and July 31, 3002. There are three groups of Responders in the WTC Health Program: FDNY Responders and Family Members, NYC General Responders (including NYPD), and Pentagon and Shanksville PA Responders.

Social Worker (SW) Assess psychosocial needs and assist members and CM team in obtaining required resources and navigating social services.

Survivor Also known as NYC Survivors; Includes individuals who were present in NYC Disaster Area in the dust or dust cloud on September 11, 2001; individuals who lived, worked or went to school or childcare, or adult child care in the NYC Disaster area for a certain amount of time during the period between September 11, 2001 and July 31, 2002; certain cleanup and maintenance workers; and certain individuals eligible (or whose place of employment was eligible) to receive certain grants from the Lower Manhattan Development Corporation

Utilization Management (UM) Review Nurse

Nurse(s) responsible for managing and conducting the Utilization Review process. Nurse will provide the first level medical necessity review.

Acronyms and Definitions

Term Definition

Case Management Society of America (CMSA)

An organization facilitates the growth and development of professional case managers across the full health care continuum, promoting high quality, ethical practice benefitting patients and their families.

Case Management (CM) A collaborative process of assessment, planning, facilitation, and care coordination to address member needs.

Utilization Management (UM) The process of evaluating medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

New York Metropolitan Area

(NYMA)

An area specified by the Administrator to include portions of New York, New Jersey, Connecticut, and Pennsylvania;

Program members residing within the area may access CCEs for their WTC-related health care.

Registered Nurse (RN) A licensed medical professional able to provide and coordinate patient care and education in various settings.

Social Worker (SW) Well-trained professionals who aim to enhance overall well-being and help meet basic and complex member needs.

Initial Health Evaluation (IHE) The first health evaluation for a member to determine eligibility for benefits within the Program.

Durable Medical Equipment

(DME)

Medical equipment used in a member’s home, such as CPAP machines and wheelchairs.

Intensive Case Management

(ICM)

High level of case management services for those members with the highest level of acuity/complexity.

Plan of Care (POC) A care plan developed for each member requiring ICM based on individual member needs.