Back to Basics: Improving the Quality of Your Case Management Services

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Back to Basics Improving the Quality of Your
Case Management Services
Julia Hidalgo, ScD, MSW, MPHPositive
Outcomes, Inc. George Washington
Universitywww.positiveoutcomes.netjulia.hidalgo_at_
positiveoutcomes.net
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EFFECTIVE ELIGIBILITY DETERMINATION IN THE RYAN
WHITE PROGRAM AND OTHER SYSTEMS
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Why conduct eligibility determination for HIV
clients?

• Adhere to the federal Ryan White HIV/AIDS
  Treatment Modernization Act of 2006
• Ensure clients receive the optimal benefits that
  they are legally eligible
• Ensure access to health care and medications
  through enrollment in ADAP, AICP, or other public
  programs
• Through enrollment in commercial insurance,
  ensure access to a full range of health care
  benefits not commonly covered by the Ryan White
  Program
• Ensure income maintenance through disability
  income and other income maintenance programs
• Ensure that HIV clinics and other health care
  providers are compensated for their services

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Ryan White Program Payer of Last Resort Policies

• The Ryan White Program is the payer of last
  resort (PLR)
• Grantees and subgrantees (i.e., contractors) must
  ensure that clients meet eligibility criteria for
  Ryan White-funded services
• Including ADAP, AICP, and direct services
• Grantees and subgrantees must ensure that
  alternate payment sources are pursued before
  providing Ryan White-funded services
• Grantees must establish and monitor procedures to
  ensure that their subgrantees verify and document
  client eligibility

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Payer of Last Resort Policies

• Direct service grantees and subgrantees must
  document that their clients are screened for and
  enrolled in eligible programs and their benefits
  are coordinated after enrollment
• Medicare, Medicaid, private health insurance
• Other programs include public housing, drug or
  mental health treatment, or Food Stamps
• Income assistance, including disability income
  and Temporary Assistance to Needy Families (TANF)
• Grantees must coordinate with other funders to
  ensure that Ryan White Program funds are the PLR
• Including coordination with the VA
• These and other HAB requirements are subject to
  audit

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Components of Eligibility Determination

• Applicants identify
• HIV seropositive status, or affected family
  member (for some services)
• Residency
• Health insurance enrollment
• Income

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Eligibility Determination Pieces of the Puzzle

• There is a vast array of entitlement and
  discretionary programs that HIV clients may be
  eligible for today and tomorrow
• Eligibility criteria (the short list)
• Geographic residency, US citizenship, legal
  residency status, age, gender, previous financial
  contributions by client, employment status, type
  of employer, preexisting medical condition,
  disability, employability, income, assets, HIV
  serostatus, CD4 count, annual or lifetime
  utilization of benefits, criminal convictions

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Medicaid Eligibility For HIV/AIDS Beneficiaries
Adapted from Kaiser Family Foundation HAB
presentation
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SSI and HIV/AIDS

• Substantial state variability in the acceptance
  rates of SSI applications from HIV individuals
• Initial denial rates tend to be very high in most
  states
• Significant changes are being made to State
  Medicaid programs due to the Deficit Reduction
  Act (DRA)
• Example beneficiaries and applicants must
  document their US citizenship
• Disability claims are taking longer than ever to
  process
• Many State and federal entitlement programs have
  had layoffs or are working with inexperienced
  staff
• New SSI HIV/AIDS disability criteria was
  published in June 2009
• Adults http//www.ssa.gov/disability/professional
  s/bluebook/14.00-Immune-Adult.htm
• Children http//www.ssa.gov/disability/profession
  als/bluebook/114.00-Immune-Childhood.htm

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SSI and HIV/AIDS

• In Florida, the Division of Disability
  Determinations (DDD) makes decisions regarding
  the medical eligibility of Floridians applying
  for disability benefits under the federal SSDI,
  SSI, and the state Medically Needy program
• DDD is also responsible for redeterminations
• Applications for disability benefits are filed at
  the local Social Security Administration field
  office when an claimant seeks disability benefits
  under the Social Security Act, or at a local DCF
  office of the when benefits are sought for the
  Medically Needy program
• The application is forwarded to DDD for a
  determination of medical eligibility
• The claim is then returned to either SSA or DCF
  for a final determination of non-medical
  eligibility and effectuation of any benefits due
  the claimant
• What has been your HIV clients experience
  applying and enrolling in Medicaid?

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Medicare Eligibility For HIV/AIDS Beneficiaries

• Medicare Part D Enrollment
• Implementation was challenging
• HIV Medicare beneficiaries continue to express
  challenges in comparing plans
• What has been your HIV clients experience with
  Medicare Part D?

Adapted from Kaiser Family Foundation HAB
presentation
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Pop Quiz

• What is the difference between SSI and SSDI?
• Can you be enrolled simultaneously in Medicaid
  and Medicare?
• True or false? A client cannot be enrolled in
  Medicaid and Ryan White-funded programs?
• Under what circumstances can a Medicare
  beneficiary receive Ryan White-funded services?

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Commercial Insurance

• Coverage is primarily through group benefits via
  employers or association membership
• Individual coverage can be purchased through
  carriers
• Benefits vary substantially among carriers
• ED must address
• Waiting periods for pre-existing medical
  conditions
• Annual or lifetime caps
• Service utilization limits for specific services
  (e.g., number of prescriptions, home health
  visits)
• HIV beneficiaries of these plans may receive
  Ryan White Program benefits during waiting
  periods or while services caps are exceeded

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Commercial Insurance

• Some eligible HIV individuals do not seek
  insurance or drop their coverage due to
• Concern about HIV disclosure and discrimination
• Growing premiums, co-payments, and deductibles
• Case managers should not encourage enrollment in
  Ryan White Program-funded programs as a
  substitute to health insurance available to them
• However, assistance may be available through AICP
• It is important to counsel clients
• To retain or seek coverage during open season
• Seek improved coverage if they have limited
  benefits or high premiums, co-payments, or
  deductibles

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Pop Quiz

• Can you be enrolled simultaneously in commercial
  insurance and Ryan White-funded programs?
• Can a Ryan White-funded program accept commercial
  insurance?
• Under what circumstances can a commercial
  insurance beneficiary receive Ryan White-funded
  services?

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What is HABs policy regarding veterans?

• In 2004, HAB clarified their policy about
  providing Ryan White Program-funded services to
  HIV veterans who also are eligible for VA
  benefits http//hab.hrsa.gov/law/0401.htm
• Ryan White Program providers
• Should inquire if a client is a veteran and
  enrolled in the VA
• May not deny services, including medications, to
  veterans who are otherwise eligible for the Ryan
  White Program
• Should be knowledgeable about VA medical
  benefits, including medications
• Must coordinate health care benefits for veterans
• Make HIV veterans aware of VA services
  available, procedures for getting VA care, and
  help them to navigate HIV care
• Even if enrolled in the VA, a veteran does not
  have to use the VA as their exclusive health care
  provider

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What are the eligibility criteria for veterans to
receive services from the VA?

• Eligibility information is available at
  http//www.va.gov/healtheligibility/HECHome.htm
• Eligibility for most veterans health care
  benefits is based on active military service in
  the Army, Navy, Air Force, Marines, or Coast
  Guard, and other criteria
• VA health care benefits are not just for veterans
  who served in combat or have a service-connected
  injury or medical condition
• Not all veterans are eligible for VA benefits
• In recent years, VA eligibility requirements
• have become increasingly strict

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Eligibility for Other Publicly Funded Services

• Under the Ryan White Program PLR policy, if a
  client is eligible for services through other
  publicly funded services they should be referred
  to those services before Ryan White
  Program-funded services should be provided
• Examples include
• Substance abuse treatment services
• Mental health services
• Food/pantry services
• Transportation
• Utilities assistance
• What challenges have your HIV clients
  experienced enrolling in these programs?

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POP QUIZ TRUE OR FALSE1. Physicians and other
clinicians can help HIV patients to enroll in
Medicaid2. The reception staff at HIV clinics
can assist in periodic re-determination of health
insurance coverage3. Re-determination should
only be done once per year4. I am very familiar
with eligibility requirements for Medicaid,
Medicare, ADAP, and my states Health Insurance
Continuation Program
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Partners in Effective ED
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Partners In Eligibility Determination

• Clients
• Direct service agency managers and HIV program
  directors

• Case managers or other ED staff
• Physicians documenting disability
• Reception staff
• Other payers and other systems
• Legal advocacy programs

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Effective Strategies In Working With Clients

• Communicate with clients that to continue to
  operate, your program must have revenue
• Avoid the attitude dont ask, dont tell,
  giving the clients the impression that there is a
  free lunch
• Providers are often unaware that clients are
  already enrolled or eligible for care
• Concerns about discrimination and stigma are real
  and may result in lack of complete disclosure
• Do not assume that clients can navigate the
  system, read, or complete forms
• Conversely, do not assume that clients cannot
  navigate the system when some can
• ED processes that rely heavily on clients are
  commonly doomed
• Paperwork is not the highest priority when you
  are trying to survive
• Ensure that clients receive the maximum benefit
  to which they are legally entitled
• What other strategies do you use?

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Role of HIV Program Directors and Case
Management Supervisors

• Link with HIV clinics to obtain documentation of
  clients HIV serostatus
• Case managers working in clinics must document
  HIV serostatus in your clients case management
  charts
• Use standardized forms and train personnel to use
  them
• Ensure forms are linguistically appropriate to
  the subpopulations served
• Address the varied literacy level of clients
• Clearly identify expectations to case managers
  regarding chart documentation
• Require tax returns or credit checks to document
  income, assets, and employment

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Role of HIV Program Directors and Case
Management Supervisors

• Some agencies find electronic case management
  software helpful in ED screening
• It is important that the software be updated
  regularly to reflect new programs or changes in
  existing programs
• Reflect the availability of state and local
  programs
• Review your policies and procedures with your ED
  staff to determine what is actually being done
• Talk to your staff, assess data, and conduct your
  own audits
• Develop continuous quality improvement (CQI) to
  improve ED
• Train and retrain ED staff and test their
  knowledge periodically
• Use trained and experienced supervisors

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Role of HIV Program Directors and Case
Management Supervisors

• Systematically assess the ED processes by
  applying performance standards and auditing
  charts
• Use benchmark data to compare the performance of
  ED staff
• Do not assume that your programs case managers
  are handling it
• Many case managers report that their case loads
  are too high and that they are not trained to
  handle ED
• Assess if case managers are the most
  cost-effective personnel model for ED
• Identify entitlement and discretionary programs
  for which there are barriers to enrollment
• Document the problem and establish ongoing
  processes for resolution an important advocacy
  role
• Communicate with other HIV programs to document
  system-wide barriers
• How do supervisors in your agency monitor ED
  functions of your HIV case managers?

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Role of HIV Program Directors and Case
Management Supervisors

• Routinely monitor changes in entitlement and
  discretionary programs that impact eligibility
  and adjust accordingly
• Changes to major payers in your community should
  be rapidly communicated to ED workers
• Meet with county DSS staff to become familiar
  with their processes, get on the list for program
  announcements, and ask if your staff can
  participate in training
• Do not assume another agency will take care of ED
  unless that explicit role is assigned to them
• Coordinate with community partners if another
  agency is responsible for ED
• Determine how client-level will be transmitted
  effectively between agencies, with HIPAA
  requirements addressed for data transfer

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Role of HIV Program Directors and Case
Management Supervisors

• Collaborate with other care systems to identify
  resources and coordinate referrals
• Other systems include substance abuse and mental
  health treatment, affordable housing,
  pantry/nutrition programs, transportation, etc.
• Legal services may be available (through Ryan
  White-funded programs or referral) to pursue
  administrative procedures following rejected
  disability or other claims and to assist clients
  in employment discrimination cases
• Establish processes with SSA to fast track
  applications and to train disability
  determination staff regarding HIV disease
• Are there other actions your HIV program director
  or supervisor can do to help you do ED?

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Strategies For HIV Programs

• Receptionists should ask ALL clients at EACH
  visit for a copy of their health insurance card,
  including Medicare Part D enrollment card
• Any changes should be reported to the case
  management staff
• It is important that receptionists not assume
  that no change has occurred
• At the beginning of each calendar year, it is
  important to confirm insurance status
• Scheduling staff should confirm through the
  online Medicaid system that the client is newly
  or still enrolled
• Confirm Medicaid enrollment the day before the
  clients appointment
• What if our agency is not a Medicaid provider?
• Copies of new health insurance cards should be
  made and filed in the clients chart

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Effective ED Strategies

• Do not front-loaded ED at entry in care
• Screen for eligibility on a routine basis (e.g.,
  every six to twelve months)
• Use rolling re-determination to normalize
  required staffing
• Intake and re-determination forms should be
  tailored to screen for the unique set of health
  and other programs in your community
• It is not enough to ask a client if he/she is
  enrolled but assess eligibility based on the
  criteria used for relevant programs
• Knowing how to complete the paperwork, document
  claims, and making sure clients follow through
  are the keys to success
• Request the case management charts of new clients
  moving from other states

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Effective ED Strategies

• Medical providers must communicate with ED staff
  about eligibility triggers
• Loss of employment due to disability, inability
  to be employed due to the side efforts of HAART,
  inpatient admissions, changes in clinical
  condition
• Do not assume that clients disability claims
  should only be HIV-related, they may have other
  chronic conditions
• Coordinate applications for benefits
• Avoid flooding the system with completed forms to
  see what sticks
• Do not advise clients to get a Medicaid
  rejection letter so they can access Ryan White
  Program-funded services
• Rather, work with clients to prepare valid,
  accurate applications for benefits
• Partner with legal aid staff to prepare well
  documented applications and address
  discrimination issues
• What other strategies do you use?

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Documenting Eligibility for the Ryan White
Program and Other Funded Services
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Health and Case Management Record Basics

• The chart or record is the core element of a
  visit or other unit of service
• Since eligibility determination services are
  purchased by the Ryan White Program or health
  insurers, requirements for medical records are
  applicable to case management records
• It is a systematically organized record of a
  clients total care
• Everyone who records progress of care in the
  record should follow the same note writing format
• Policies and procedures dictate its organization
  and use
• Creates a verifiable record of services provided
  for third party payers and other interested
  parties (QI, accreditation, etc.)
• As such, the record should be easily navigated by
  an external chart reviewer for audit or quality
  assessment

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ED Documentation

• Documentation provides the who, what, when,
  where, why, and how of client care
• Regardless of the complexity of documentation,
  records must be comprehensive enough to meet
  regulatory, licensing, accreditation, legal,
  research, quality assurance, and client care
  needs and purposes
• Record notes must be comprehensive enough to
  support the design and implementation of the care
  plan and the nature of case management services
  provided

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ED Documentation

• Information should be recorded at the time of
  care
• At least on the same day
• The longer the delay, the lower the quality of
  the entry
• All staff should use the same set of approved
  abbreviations and symbols
• All entries must be dated, timed, chronological,
  legible, and signed in non-erasable blue or black
  ink by the provider with his/her credentials
  noted after their name
• No blank spaces in between entries
• Do not use WhiteOut or highlighters
• Corrections can only be made with a new entry,
  then cross out and initial old entry
• If its not legible, its not there if its not
  there, it wasnt done

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Case Conferences
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Pop Quiz Who is the Client? Case 1

• Antonio is a 45 year old HIV construction worker
  that recently relocated to Orlando from New York.
  He and his HIV wife have two children ages five
  and two. His wife recently left him, and he is
  caring for the children on his own. Antonio has
  advanced HIV disease, and chronic orthopedic
  conditions that prevent him from working. He
  reports having no income, no health insurance,
  and is worried that he cannot care for his
  children.

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Pop Quiz

• Our case management program is located in a
  clinic, should we consider consolidating the
  medical and case management record? When can case
  managers write notes in the medical chart?
• Should case managers read their clients medical
  record? Should a community case manager request a
  copy of their clients medical record?
• Should case management record be filed centrally?
• Should case managers take client records with
  them to visit their clients at home, in the
  hospital, etc.?
• When should automated case management records be
  downloaded onto a disk or flash drive?
• Can a client request a copy of their case
  management record?

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Pop Quiz Who is the Client? Case 1

• This is what we know from intake
• Antonio is a 45 year old HIV construction worker
  that recently relocated to Orlando from New York.
  He and his HIV wife have two children ages five
  and two. His wife recently left him to care for
  the children on his own. Antonio has advanced HIV
  disease, and chronic orthopedic conditions that
  prevent him from working. He reports having no
  income, health insurance, and is worried that he
  cannot care for his children.

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Pop Quiz Who is the Client? Case 2

• This is what we know from intake
• Marvin is a 50 year old HIV male that lives with
  his 75 year old mother. He has been HIV for
  seven years, with a declining CD4 count and
  increasing viral load. He is often is too
  depressed to go to his HIV clinic visits, take
  his medications, or care for himself. At intake,
  Marvins mother is unaware that he is HIV. At
  the advise of his case manager, Marvin tells his
  mother that he is HIV. She is depressed and
  anxious, as she worries that Marvin may die.

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Case Conference 4

• This is what we know from intake
• Marvin is a 45 year old mechanic. He was
  diagnosed ten years ago with HIV and has several
  opportunistic infections and hospital stays. He
  is on salvage HAART. Marvin reports that he can
  no longer work due to ill health. Currently,
  Marvin is enrolled in health insurance. He also
  reports that it is becoming difficult to maintain
  his apartment, drive to the store, and prepare
  his meals. His physician reports that Marvin is
  showing signs of HIV dementia and wasting.