Tailord Care Managers Idd/ Mh

Purpose of service and position:
PQA’s Tailored Care Management program will manage the comprehensive needs of people served by the program. Tailored Care Management will promote whole-person care, foster high-functioning integrated care teams, and drive towards better health outcomes. Tailored Care Management will require Care Managers to coordinate physical health, behavioral health, I/DD and traumatic brain injury (TBI) services.
Program Setting
Tailored Care Management will be performed at the site of care, in the home or in the community, through face-to-face interaction between beneficiaries, providers, and Care Managers.
Care Manager Responsibilities:
Overall:
Care Managers will perform all Tailored Care Management program functions in accordance with all PQA policies and procedures, the NC State DHHS Provider Manual and all Tailored Care Management Program expectations.
Communication/Contacts:
Care Managers must follow policies and procedures for communication with members, their families and other caregivers with appropriate consideration for language, literacy, and cultural preferences, including sign language, closed captioning, and/or video capture.
Care Managers must follow requirements for contact with members under the Tailored Care Management model including the level of minimum contacts according to the members acuity level.
Care Management Comprehensive Assessment:
Care Managers will complete the Care Management Comprehensive Assessment (including all required components) which will be a person-centered assessment of a member’s health care needs, functional needs, accessibility needs, strengths and supports, goals, and other characteristics that will inform the ongoing care plan or ISP and treatment. The Care Management Comprehensive Assessment will help to consolidate information across physical health, behavioral health, I/DD, TBI, LTSS, pharmacy, unmet healthrelated resource needs, and other needs and inform the care plan or ISP. Care Managers will complete Care Management Comprehensive Assessments in accordance with methods, timelines, and other details in the Tailored Care Management Provider’s Manual.
Care plans and Individual Support Plans (ISPs)
Care Managers must develop a care plan with all required content for each member with behavioral health needs and/or an ISP for each member with I/DD and TBI needs. Each care plan and ISP must be individualized, person-centered, and developed using a collaborative approach including member and family participation where appropriate. Care plans and ISPs must incorporate the results of the Care Management Comprehensive Assessment (including unmet health-related resource need questions), claims analysis and risk scoring, any available medical records, and screening and/or level of care determination tools.
Required Components of Tailored Care Management.
Once care management has been initiated through the completion of the Care Management Comprehensive Assessment and formation of the care team, the Care Manager will ensure that all of the following components of Tailored Care Management are available to enrolled members:
• Care Coordination: The Care Manager must ensure the member has an ongoing source of care and coordinate the member’s health care and social services, spanning physical health, behavioral health, I/DD, TBI, LTSS, pharmacy services, and services to address unmet healthrelated resource needs (see Section 4.7 below). Care coordination includes following up on referrals and working with the member’s providers to help coordinate resources during any crisis event as well as providing assistance in scheduling and preparing members for appointments (e.g., reminders and arranging transportation). Care coordination also includes provision of referral, information, and assistance in obtaining and maintaining communitybased resources and social support services, including LTSS; I/DD and TBI services (including Innovations and TBI waiver services); and any State-funded services.
• Twenty-four-Hour Coverage: AMH+ practices and CMAs must provide or arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis, 24 hours per day, seven days per week. This requirement includes the ability to (1) share information such as care plans and psychiatric advance directives, and (2) coordinate care to place the member in the appropriate setting during urgent and emergent events. Automatic referral to the hospital ED for services does not satisfy this requirement.
• Annual Physical Exam: The Care Manager must ensure that the member has an annual physical exam or well-child visit, based on the appropriate age-related frequency.
• Continuous Monitoring: The Care Manager must conduct continuous monitoring of progress toward goals identified in the care plan or ISP through face-to-face and collateral contacts with the member and his or her support member(s) and routine care team reviews. The Care Manager must support the member’s adherence to prescribed treatment regimens and wellness activities.
• Medication Monitoring: The Care Manager must conduct medication monitoring, including regular medication reconciliation (conducted by the appropriate care team member) and support of medication adherence. A community pharmacist at the CIN level, in communication with the AMH+ or CMA, may assume this role.
• System of Care: The Care Manager must utilize strategies consistent with a System of Care44 philosophy for children and youth, including knowledge of child welfare, school, and juvenile justice systems. For children and youth receiving behavioral health services, care management must include:
• Promotion of family-driven, youth-guided service delivery and development of strategies built on social networks and natural or informal supports;
• Development of, with families and youth, strategies that maximize the skills and competencies of family members to support youth and caregivers’ self- determination and enhance self-sufficiency;
• Verifiable efforts for services and supports to be delivered in the community within which the youth and family live, using the least restrictive settings possible in order to preserve community and family connections and manage costs; and
• Development and implementation of proactive and reactive crisis plans in conjunction with the care plan or ISP that anticipate crises and utilize family, team and community strengths to identify and describe who does what and when; every member of the CFT shall be provided a copy of the plan.
• Individual and Family Supports: The Care Manager must ensure that the care management approach incorporates individual and family supports including: Educating the member in self-management; Providing education and guidance on self-advocacy to the member, family members, and support members; Connecting the member and caregivers to education and training to help the member improve function, develop socialization and adaptive skills, and navigate the service system; Providing information and connections to needed services and supports including but not limited to self-help services, peer support services, and respite services; Providing information to the member, family members, and support members about the member’s rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes; Promoting wellness and prevention programs; Providing information on establishing advance directives, including psychiatric advance directives as appropriate, and guardianship options/alternatives, as appropriate; Connecting members and family members to resources that support maintaining employment, community integration, and success in school, as appropriate; and For high-risk pregnant women, inquiring about broader family needs, offering guidance on family planning, and beginning discussions about the potential for an Infant Plan of Safe Care.
• Health Promotion: The Care Manager must address the following items for health promotion: Providing education on members’ chronic conditions; Teaching self-management skills and sharing self-help recovery resources; Providing education on common environmental risk factors including but not limited to the health effects of exposure to second and third hand tobacco smoke and e-cigarette aerosols and liquids and their effects on family and children; Conducting medication reviews and regimen compliance; and Promoting wellness and prevention programs.
Additional TCM Components:
Tailored Care Management also includes the following components:
• Addressing unmet health-related resource needs,
• Transitional care management, and
• Innovations and TBI Waiver Care Coordination (if applicable).
These components will be completed in accordance with the Tailored Care Management Provider’s Manual.
Training:
All Care Managers, care manager extenders, and supervisors conducting Tailored Care Management will be required to undergo an intensive training curriculum, regardless of previous experience.
Qualifications:
Care managers serving members with behavioral health conditions must have the following minimum qualifications:
• A bachelor’s degree in a field related to health, psychology, sociology, social work, nursing, or another relevant human services area, or licensure as a registered nurse (RN);
• and Two years of experience working directly with individuals with behavioral health conditions (if serving members with behavioral health needs) or with an I/DD or a TBI (if serving members with I/DD or TBI needs);
• and For Care Managers serving members with LTSS needs: two years of prior LTSS and/or HCBS coordination, care delivery monitoring, and care management experience, in addition to the requirements cited above. (This experience may be concurrent with the two years of experience working directly with individuals with behavioral health conditions, an I/DD, or a TBI, above.
Additional Requirements: A valid driver’s license as applicable. A driver’s license check, criminal background check, and health care personnel registry check. Must pass pre-employment drug screen. Keep CPR and First Aid current. Complete all required trainings.