Care Management

welcome to this introduction to care management in the comprehensive class member transition program provided by the uic college of nursing this training will enable participants to define care management and the care management process understand the roles and responsibilities of care managers and effectively implement care management for colbert and williams class members care management is defined as a person-centered team-based approach to working with a class member the team includes the member their family or caregiver their care manager and the members medical and psychiatric providers care management aims to effectively integrate health care and social supports care management has been evolving since the early 1900s and is now a core component of chronic condition management while the terms care coordination and care management have at times been used interchangeably there are important differences between them care coordination is the process of identifying member needs linking the member to appropriate services and ensuring that the members needs are communicated clearly to all other participants in the members service plan care management however involves assessment collaboration with other providers working with social supports as well as developing implementing and evaluating a comprehensive member-focused service plan care management involves intensive care coordination in addition to this broader set of tasks the foundation of care management is assessment an effective care management assessment is a comprehensive multi-disciplinary evaluation of the member that looks at and prioritizes the members goals strengths challenges and barriers to care this assessment should be thorough and ongoing with new details added as the care manager learns more about the member from assessment the care manager develops a comprehensive plan of care in collaboration with the member and their supports this care plan is implemented proactively monitored and evaluated using evidence-based guidelines standards of care and best practices this service plan incorporates the members self-management of their health conditions medication management health promotion and wellness activities and all of their providers services and supports when a member’s level of care changes or their treatment plan is updated the care manager manages these transitions by following up in a timely fashion facilitating clear and effective communication between the member providers and other supports and adjusts the care plan to reflect the members new status while these are indicated here as separate steps or phases the care management process is truly an ongoing evolutionary process that includes ongoing assessment planning implementation and evaluation to ensure that the member is receiving the most effective care possible care management when properly implemented provides several benefits first and foremost members who receive effective care management report an increased quality of life they are more likely to be safe and successful in the community in addition members more efficiently use community-based medical and psychiatric resources when they are working with a care manager care management can result in more stability and independence health and psychiatric well-being are promoted and functional needs are addressed this leads to fewer hospitalizations more manageable symptoms and increased self-management ability financial savings for the health care system as a whole as well as for the member can also result through improvement of health and independence and reduced use of high expense settings such as emergency departments acute care and long-term care within the comprehensive class member transition program care management has several specific goals these include increased independence for members enabling them to engage in more of the activities they enjoy in addition members will increase self-management through the support of a care manager this includes self-management across domains including medical psychiatric functional and community needs effective care management will also

result in fewer hospitalizations a lower incidence of reinstitutionalization and less utilization of emergent or acute medical care which will decrease costs for the member and for the medical system as a whole finally care management will make the entire transition process more efficient and allow members to spend less time waiting on the transition process and more time enjoying and sustaining their independence in the community the care management process has several interrelated aims care management supports members participation in their own health care decisions in management care management also supports members self-management of their chronic health conditions and their adherence to their prescribed medication regimens care management can enable members to better participate in health promotion and wellness activities care management also fosters increased collaboration among and between participants in the service plan including the member family and caregivers medical and psychiatric providers and the care manager this facilitates better coordination between providers and continuity of care throughout the members involvement and services effective care managers are constantly monitoring and evaluating the effectiveness of care plans as they are implemented and working to address and resolve barriers quickly this rapid response to problems will enable members to have improved health outcomes increased satisfaction with services and a better quality of life ultimately well-planned care management results in members receiving cost-effective care in the least restrictive possible environment the care manager wears many hats throughout the process of care delivery the central process of care management engagement assessment planning implementation monitoring and evaluation is the foundation of all of the care management activities these care management activities include coaching educating and empowering collaborating and coordinating managing documenting advocating and negotiating and facilitating and supporting we will review each of those tasks shortly the skilled care manager identifies the member specific needs and applies the applicable roles throughout the care management process just as the needs of class members evolve over time the role of the care manager with a specific member will evolve over time it is vital a care manager is skilled in each of these areas and applies them based on the members needs one of the primary activities of care management is to assess this means to assess in the broadest possible terms the members health status their goals strengths and risks any barriers to care unmet needs and acknowledging the members self-management abilities all of the care manager’s other roles and activities rest upon the foundation of solid ongoing assessment care managers also develop plan and implement care plans these care plans should be based on evidence-based guidelines best practices and standards of care and include the input and participation of the member family caregivers and other medical psychiatric and service providers the care manager is responsible for not just building and planning the care plan but also the implementation and monitoring of the plan elements care managers are responsible for coaching teaching and empowering as well this includes building the skills knowledge and confidence of the member their family and the caregiving team this teaching will build the abilities of the member and their supports to self-manage the members health conditions medication regimen red flags and warning signs and any other identified problems or risks ultimately the care manager is responsible for increasing the member’s level of independence with regards to all of their condition management skills community engagement and independent living skills care management is an inherently collaborative function care managers are responsible for coordinating the member’s care plan with partners in other disciplines whether the care manager is a nurse social worker or other professional they will be working with a broad spectrum of

providers including medical providers pharmacists nurses social workers facility staff and home health providers among others care managers must be able to effectively facilitate communication between different types of person this may include interpreting medical information for a member or their supports helping a member communicate their symptoms or changes in status to a provider and ensuring the providers from different disciplines have a shared understanding of the member’s status and needs in addition to collaboration care managers must coordinate all of the care the member is receiving this includes the formal service providers and supports involved in the members care plan but also the informal supports who may be providing services on an ad hoc or intermittent basis ensuring that the member’s care needs are met at all times becomes a significant part of the care manager’s role care management is a supportive role as well care managers must support the member and their family caregiver and other supports in implementing the care plan they also support the participants in reporting changes in status including any new challenges or successes members also require support from their care managers when it comes to advocacy care managers help members by advocating for them and their families to receive the necessary services and the proper level of care this may involve negotiating with other players in the members care plan members may require support or advocacy in negotiations with their providers or insurance plan in order to access the services they require while care managers may conduct this negotiation independently their role may also be to help the member develop negotiation skills so they can advocate for themselves thus increasing the member’s independence as the care plan is implemented the care manager must continually monitor and evaluate it this includes observing and tracking the effectiveness of the plan and adapting it as needed to accommodate changes in the member’s life care plans should be revised based on ongoing evaluation to reflect changes in the member’s health status psychosocial needs or self-management abilities care plans are a living document that should always reflect a current understanding of the member’s situation the care manager is responsible for maintaining effective documentation on every element of the care management process this includes not just formal documents like assessments or the service plan but the day-to-day logging of the activities the care manager completes this is important for keeping track of the care manager’s activities for funder requirements but also serves as a way of ensuring that another care manager could pick up where the prior manager left off in the event the care manager is unavailable or the agency experiences a staffing change the adage if it’s not documented it didn’t happen definitely applies to care management finally the management part of care management the care manager is responsible for ensuring that transitions of care happen as smoothly as possible with minimal disruption to the members health this includes obvious transitions like the move from a nursing facility or smurf to the community but also covers smaller transitions such as introducing a new provider into the care plan or a change in the member’s family that impacts the member’s care care management follows a cyclical process this process occurs within each contact as well as throughout the member’s engagement in the program the class member and the class member support is always at the center of the care management process in the relationship with the class member the care manager begins by building engagement with the member this includes building rapport helping the member understand the care manager’s role and providing information about the program to the member this is followed by assessment which includes a formal assessment like the comprehensive program assessment as well as informal observations over time the care manager then develops the care plan which is subject to ongoing revision next the plan is implemented as the member receives the services

indicated in the plan the care manager is monitoring and evaluating the implementation while also maintaining engagement ongoing assessment leads to revisions in the plan and adjustments in implementation while this diagram is depicted as a circle multiple phases of the process occur simultaneously and the overlap between phases is an integral part of the care management process during each individual encounter the care manager also engages in each of these steps opening and engaging the member assessing the member’s current status adjusting care plans implementing these plans and evaluating outcomes in the comprehensive class member transition program care management can be thought of as having multiple phases the goal of effective care management is to smoothly transition between these phases without encountering barriers to transition or having information about the member be lost the pre-transition phase can be thought of as encompassing outreach assessment and all of the other activities that take place up until the members transition day these aren’t siloed phases of a transition process but should all be part of a fluid process from outreach through move out activities can and should happen simultaneously outreach and comprehensive assessment are addressed in other trainings focused on these aspects of the transition process however ongoing engagement and further assessment take place throughout the transition process in addition service planning is both a concrete task that is filling out the comprehensive service plan document but also an ongoing process in addition before transition the care manager is responsible for ensuring that the member has all necessary documents to facilitate transition this can include a state id or driver’s license a social security card a birth certificate proof of naturalization or other member specific documents that might be necessary to secure housing and benefits the care manager is also involved in coordinating additional assessments that might be necessary these could include occupational therapy or uic atu evaluations nursing or integrated health assessments neuropsychological testing or agency mental health assessments the housing search phase of pre-transition activities can be lengthy especially for members who have legal or financial barriers to securing housing such as poor credit or a criminal history however for some members locating housing is a smooth and speedy process alongside the housing search process care managers are responsible for requesting a clinical case review for any high-risk members that is those members who are assessed in quadrant three or quadrant four discussions with facility staff and providers should occur on an ongoing basis when the member is approaching discharge from the facility a formal discharge meeting is scheduled with the nursing facility or smurf the member and other supports and providers the purpose of this meeting is to review the member’s plan and identify additional needs that will need to be addressed prior to transition ensure that all necessary tasks have been completed and to assign accountabilities to specific individuals regarding tasks that still need to be completed for some members multiple discharge meetings may be necessary to address complex situations the transition day itself concludes the pre-transition phase this involves ensuring the members housing is appropriately furnished and utilities are set up that the member leaves the facility with all their medications and medical supplies that any in-home supports are established the member is aware of appointments and how they will get there and that the member has enough food and supplies to support them for at least the first few weeks they are in their home depending on the members needs and agency protocols transition day tasks may also include taking the member to social security to report their discharge from the facility arranging initial visits with nursing staff or other providers the care management process begins with the engagement step in the comprehensive program this starts at the outreach stage

while other staff may be completing the core actions of this stage the care manager is ultimately responsible for ensuring that the tasks are completed the purpose of engagement is to develop and maintain a relationship with the class member this also includes connecting with the member’s guardian if they have one as well as their family or other social supports once the member is interested in moving forward with being assessed for transition a key action within this stage is to obtain effective informed consent this is addressed in more detail in another training but is a crucial element of beginning engagement with the member along with obtaining informed consent engagement involves connecting with the members other providers and supports and this requires the member to complete and sign releases of information for these individuals and organizations engagement with class members guardians family support and providers continues throughout the class members progression through the program continued engagement is essential to maintaining relationships and essential to progress towards the goals of engagement and treatment skill development and community integration the assessment stage involves both the comprehensive program assessment the formal written document as well as ongoing assessment as more information is gleaned about the member assessment also requires very clear documentation as this information is gathered and synthesized if the information is not gathered as part of a formal assessment such as during a home visit information gathered should be clearly documented within notes this should include both subjective what is reported and objective what is observed information the care manager obtains this ongoing assessment information from conversations with the member their guardian or family and other supports additional information is gained from nursing facility or smurf records as well as conversations with other health care providers or reviewing other records in addition assessment includes agency assessments such as the imcans as well as occupational therapy or nursing assessments another valuable resource for obtaining information about the member that can guide assessment and planning is the medicaid claims data this is requested by uic college of nursing for all colbert and williams class members and is made available to their prime agencies ultimately the goal of assessment is to gain a complete and comprehensive understanding of the members needs risks and challenges as well as their strengths and goals assessment also involves identifying barriers to transition and beginning to consider ways around them in tandem with assessment planning is a key part of the care management process this includes the formal comprehensive service plan as well as regular and ongoing updates planning may also include action plans which are plans to address immediate concerns that do not need to be sustained long term service plans take the information captured in the initial and ongoing assessment and builds on the members needs strengths challenges and barriers the plan should work towards the members goals using available resources in the community the care manager should ensure that the plan covers all of the domains of the members needs it should also reflect a prioritization of needs the most pressing items should be identified as being addressed first effective service plans involve other people beyond the member and the care manager this includes the member’s family or other supports the agency’s interdisciplinary team other providers facility staff etc they should also incorporate evidence-based guidelines and best practices based on the members needs finally service plans should not just focus on the specific services available within a particular agency but should incorporate other resources available in the community if those are the best options for addressing a member’s needs action plans are developed as needed to address immediate needs and may be reflected in case notes for example a member may express concerns about their current blood pressure reading and a headache while ongoing monitoring skill development and collaboration may be included in the service plan the immediate action documented may include items such as reviewing the log

calling the provider or escorting the class member to the hospital if indicated from the day the member is engaged by the care manager they should have an understanding of how this process will be implemented care management staff should always ensure that the member understands the next steps in the process and how these steps relate to the members goals care managers provide ongoing and regular contact based on the members needs at times this may involve more frequent contact the implementation of a service plan also relies on the involvement of the members formal or informal supports this includes other providers as well as family and social supports implementing the service plan requires the care manager to ensure that the member’s medications and supplies are obtained in sufficient quantity to prevent missed doses or other problems with adherence the members should also clearly understand the service plan and all of its components the medication list upcoming appointments the service plan document overall and the member’s 24-hour backup plan throughout the process the member should know what happens next and how that relates to the members short-term and long-term goals once the service plan begins to be implemented and the member works their way towards transition the care manager must continue to engage with the member based on the members needs as well as the requirements of the comprehensive program during this continued engagement the care manager is checking in about how effectively the service plan is being implemented and if there are areas where the plan should be adjusted in order to better serve the member if the plan needs to be adjusted it should be even if the mandatory time frame has not been reached things the care manager should be constantly monitoring and evaluating include the member’s safety and any urgent needs or red flag symptoms this includes making sure the member is continually aware of how to identify those urgent needs or red flags and communicate them to their providers the care manager also checks on the member’s level of engagement with the program with the community and with their familial and social supports monitoring the members health and their health care utilization is also important has the member gone to their appointments have they had unexpected hospitalizations or other incidents the members functional status and ability to self-manage their conditions changes naturally over time whether the member’s abilities are improving or declining these changes may necessitate modifications to the care plan the care manager must not overlook the member’s satisfaction with their transition if the member is unhappy this may indicate unmet needs the member’s progress towards goals is also important this includes both the members perception of their progress as well as the care manager’s observation of their achievement monitoring also involves keeping track of what has and has not worked for the member if there are interventions that have worked particularly well for the member it may be important to utilize them more heavily similarly if some interventions have not been effective for the member the care manager should consider de-emphasizing them in the care plan also care managers should note an attempt to address areas where additional resources may be required this process also involves some creative thinking and planning in order to overcome resource deficiencies where does the care manager get the information they need to effectively evaluate the implementation of a plan there are a plethora of resources available to learn about the members progress towards their goals these include the care managers direct observations information shared by the member or by their supports communication within and between staff and teams at an agency the member’s healthcare and other service providers an agency’s partnering or subcontracting agencies and comprehensive program resources like uic atu and the college of nursing all of this effective monitoring and evaluation means very little if it is not effectively documented the care manager must ensure that their documentation is accurate current and clear this includes case notes or progress notes reflecting actions the care manager has taken contact information for the member providers

and supports medications and diagnoses clearly documenting any changes in status or reportable incidents and making sure that the plan of care document itself is clear and complete in the comprehensive program post-transition phase the care manager must make sure that the service plan is effectively implemented this includes both the tasks that the care manager is responsible for themselves but also the other plan participants accountabilities this must be monitored consistently during in-person and phone contacts throughout the 18-month post-transition monitoring period as the members goals and needs change so should the service plan as a reminder the service plan must be updated every 180 days but can be modified sooner if the need arises monitoring the plan also includes clearly documenting all of the information gleaned about the service plan’s implementation and its effectiveness as discussed the comprehensive program post-transition monitoring period is 18 months as long as the member does not return to a nursing facility or smurf for long-term care however members are able to remain engaged with their provider for as long as they meet agency eligibility requirements even though comprehensive program monitoring is no longer necessary if care management is terminated it should be planned for just as any other service would be care managers need to contact the prime agencies assigned dmh omsu staff prior to terminating services the member needs to know that this is coming well in advance and this should be communicated through a formal termination meeting with the member at the end of that 18-month period if the member requires additional supports to be in place the care manager must ensure that there is an effective plan in place to initiate or maintain those services ideally the member has developed the independence and self-management skills during the prior 18 months to be able to meet their own needs moving forward with minimal support the care manager can effectively set the member up for success in this endeavor by properly planning for termination care management is especially crucial during transitions in care the most obvious transition in the comprehensive program is the member’s transition from nursing facility or smurf care to community housing however transitions in care also include returning to a facility or treatment program as well as hospitalizations and discharges or changes in caregivers during these transitional periods class members are at increased risk transitions may also result in increased stress and distress this can manifest as increased medical or psychiatric instability or symptom presentation adherence issues like missing medications or appointments and may result in a change in the services the member requires transitions in care require the care manager to be vigilant in providing timely and consistent follow-up with both the member and their providers as well as ensuring that information is effectively communicated between all parties involved typically transitions in care also require an adjustment to the member’s care plan as their service and care requirements have probably changed there are several additional considerations with regards to care management that must be considered in the context of the comprehensive program first information handoffs in many agencies members work with different staff or teams at different stages in the process every time a new staff person takes over the member’s care there is the potential for valuable information to be lost effective care management minimizes the number of handoffs between staff or teams and ideally has a single person responsible for following the member from outreach through termination if that is not possible ensuring that information is shared in both written and verbal form when handoffs occur is crucial and providing overlap between staff’s involvement whenever possible also helps care managers must be able to effectively collaborate within their agency across disciplines and with other providers this requires effective communication skills and an understanding of the various roles of their professional colleagues monitoring is also not the same as

surveillance care managers must balance the need for accurate and complete information with the class members right to privacy and self-determination it is important to verify the class member understands the purpose of the care manager’s actions if a class member resists involvement the care manager should reflect why this is occurring and make changes if needed care management must always be delivered in the member’s preferred language if this is not possible with multilingual staff agencies must incorporate interpreter services either in person or via a language line service while family and friends can provide informal interpretive services they can be unreliable or inaccurate translators especially around sensitive topics or with uncommon medical terms care managers should ensure that the class member is being communicated with effectively for some members this may involve non-verbal communication such as picture books or written materials work with the member to ensure their needs are being addressed effectively this ties in with cultural competency which is a vital part of care management and service delivery care managers must take it upon themselves to understand the members culture as well as their own cultural biases and expectations to ensure that the member’s care plan is not negatively impacted by implicit or explicit biases agencies should incorporate cultural competency into their staff training and professional development programs care managers may also encounter situations which involve ethical dilemmas or boundary crossings or violations with members it is important that care managers are trained on ethics and boundaries and have agency support in handling these situations care managers must also know and abide by the code of ethics of their profession and agency as well as all applicable laws rules and guidelines informed consent is the topic of another training but it is crucial to ensure throughout the process that the member understands what is happening and what they are agreeing to if a care manager is uncertain if a member can effectively understand what they are providing consent to they should take steps to ensure that the member does understand before they proceed finally agencies must have plans in place for crisis intervention as well as clinical supervision care managers must have support from their agencies with regards to professional growth and support as well as backup for addressing clinical issues that arise in the course of their work as crises occur the care manager must also have a firm understanding of what steps they should take to address the situation including which other agency staff must be involved when clinical crises occur while care management is a complicated process especially when dealing with members who have complex situations involving chronic conditions there are strategies that can ensure that it is as effective as possible early and consistent contact by the care manager is a key component in fostering successful care management frequent face-to-face contact is important in building and maintaining engagement between the class member and their care manager while phone and video contacts are helpful and an important tool for engagement and monitoring face-to-face contact provides additional assessment material and non-verbal information that cannot always be obtained remotely evidence-based practice is also crucial there is a wealth of scholarship regarding best practices for complex care management and incorporating the strategies that have been shown to be most effective with the populations we work with will increase the likelihood that these strategies are effective plans should also not be static or fixed documents they should be living breathing creations that are continually adapted to the members changing needs care managers are at their most effective when they have a strong grasp of the resources available in the members community this can be aided on an agency level by developing resource guides and individual care managers will benefit from building relationships with commonly used resources realistic goals are important in ensuring that members maintain

motivation and engagement if the care manager or member are unrealistic in their expectations the member may become demoralized or lose their sense of self-efficacy the most effective plans have goals that the member believes are attainable early and consistent care manager assignment is a key feature of the comprehensive program care management process a care manager should become involved as early in the process as possible ideally at the beginning of a member’s involvement in the program and then the same person should follow the member through the entire process while not every agency has structured their program this way this level of consistency should be maintained as much as possible relationships are at the foundation of all care management functions this includes the care manager’s relationship with the member and with their family and social supports as well as with other health care providers service providers and other community resources care manager professional development can focus on relationship building skills and effective care managers will be effective at maintaining relationships with all of these parts of their members lives all comprehensive program providers incorporate multiple disciplines in their service provision care managers social workers counselors nurses medical or psychiatric providers occupational therapists etc when these different roles function in multi-disciplinary teams they are able to approach the member’s care collaboratively from multiple professional viewpoints finally continued professional development is crucial for all care managers agencies should ensure that care management staff have clinical support and supervision as well as ongoing training and professional development to help them effectively address the broad range of situations they encounter as care managers the care management team is a valuable resource for care managers by working in a team care managers can collaboratively develop relationships with resources and share those resources with one another in addition having multiple eyes on a particular situation allows care managers to troubleshoot challenges more effectively in a team care managers in a team can also provide support to one another during challenging situations or crises as well as celebrate successes as members move through the transition process the care management team is the foundation of success for your staff as well as the members you work with the content in this presentation includes material based on scholarly research in the field of care management for more information please review the references listed here current versions of all comprehensive program policies and forms as well as educational resources can be found on the colbert and williams training website managed by the uic college of nursing any questions can be directed to the colbert williams help desk email listed on that website thank you for your attention and efforts to ensure safe and successful member transitions