The Basics

This standard, another new one in version 4.0, establishes minimum requirements for the short- and long-term goals established in the CM participant's plan.  Each goal must:

• be measurable;
• be related to the CM assessment of consumer needs;
• have a timeline for the achievement of the goal; and
• be modified as the program participant's needs change.

Management Tips

Your plan template should provide case managers with guidance such that they establish both long- and short-term goals and that each goal contain all the components required by this standard.  It is important that you implement a clear policy assuring that these goals be evaluated periodically, not just so the case manager can measure the consumer's progress against the goals, but also to see if they need to be revised in the face of changes in the consumer's needs.

URAC Accreditation Tips

Each of the four elements of this standard is worth 3 points.

For the desktop review, submit your applicable P&Ps, including care plan forms.  In addition, show evidence that staff members have been trained on your P&Ps and forms regarding the development and maintenance of care plans.

The onsite reviewer will examine case files for evidence of implementation of this standard, and will interview case managers to make sure they're fully familiar with your organization's P&Ps regarding care plans.

The Basics

This standard, new to v. 4.0, requires that at either the initial assessment or later assessments, the case manager assesses and documents:

• current health status,
• clinical history, medication history,
• treatment plan,
• medication safety issues such as medication, adherence, and the need for reconciliation. 
• necessary resourcess to address the consumer's needs,
• needs related to care coordination (including care transitions),
• psychosocial status,
• any safety concerns.

URAC defines "medication reconciliation" as follows:

The process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's admission, transfer and/or discharge orders, with the goal of providing correct medications to the patient at all transition points.

Each of these areas needs to be addressed in an assessment at some point in the process, or else you need to explain why you didn't assess an area.  That suggests that it's an excellent idea to address all of these areas as early in the process as possible.

Management Tips

The most common way to meet the requirements of this standard is to develop and require the use of a standardized clinical assessment tool, one that is used in interviews of the consumer and his/her family and providers.  In addition to such a tool, you'll need to make sure you have a P&P that describes the assessment process.

Naturally, not all these items may be appropriate for your organization's particular population, and the collection of some may even be prohibited by law. However, if the URAC reviewer, in conducting a case file review, finds that closed cases never address an area nor document why the area isn't addressed, she'll count the area as "not met."

URAC Accreditation Tips

Each of the eight elements of this standard is worth 3 points.

During the desktop review, the reviewer will expect to see your P&P describing, in detail, your assessment process as well as any tools used in that assessment.

During the onsite review, the reviewer will examine case files to find that a complete assessment has been conducted for each consumer.  In addition, the reviewer will talk with case managers about the assessment process.

The Basics

This standard, new with version 4.0, requires that the CM program conduct an annual review of the CM program.  That review must examine the program's performance measures, structure, and P&Ps.  In addition, the annual program review should use the results of case file reviews to assess whether the program's performance measures are being met.  The report of the annual review should go to the organization's quality management committee. 

Management Tips

It's helpful to think about the individual case file reviews as an invaluable window into the performance of the whole program.  This can only be accomplished if you track and trend results from those reviews.  So, be sure to design your program-level performance measures so that they are integrated with the individual case file results.  So, while individual case file audits are useful tools for assessing the performance of individual case managers, they also need to be seen as markers of program performance.

Your approach to this integration needs to be spelled out in a program description, P&Ps, or other official program document.  In addition, the documentation of the implementation of that program performance needs to be clear to an outside observer.  Finally, that report should go to the quality management committee and recorded in the QMC meeting minutes. 

URAC Accreditation Tips

Both elements of this standard are worth 3 points.

For purposes of desktop review, submit the description of your approach to program performance analysis, probably in a program description or P&P.  Also, submit sample minutes of QMC meetings at which a report of such program performance analysis is presented and discussed.

It is at the onsite review that the URAC reviewer will want to see the full documentation of the annual program performance analysis.  In addition, she will interview the case managers (and supervisors) involved in the analysis, including such questions as:

• What measures of do you use to assess the case management program's performance?
• How do those measures relate to individual case management file reviews?
• Who conducts program performance analysis?
• When was the most recent program analysis presented to the quality management committee?
• Did the discussion at the QMC of that report lead to any suggestions for changes in order to improve program performance?

The Basics

This standard requires that the case manager, using the findings of the assessment, develop a case management plan in collaboration with the consumer, members of the health care team and, if needed, experts.  In addition, the case manager should periodically update that plan should the consumer's situation or needs change. 

At a minimum, the plan must set both short- and long-term goals, identify interventions to be implemented and resources to be used in achieving those goals, create time frames for reevaluation and follow-up, and a provide description of how ongoing collaboration among the case manager, consumer, family, and providers will occur throughout the case management relationship.

Management Tips

Make sure the all elements of the plan -- and particularly the goals within the plan -- are individualized to each consumer.  The best way to assure individualization is through clear P&Ps and tools and training that link the plan development closely to the results of the CM assessment.  

What happens when a provider delegates his/her role in the collaboration to someone else?  So long as the organization documents that it made an effort to involve the provider, it will have fulfilled the intent of this standard.

URAC Accreditation Tips

All the elements of this standard carry a weight of "4".  

Documentation required is a combination of the P&P describing the CM plan development process and documentation of implementation of that P&P, including plan forms, screen shots of electronic plan forms, and the like. 

The onsite review, again, will focus on interviews with the case managers about how they go about designing an individualized CM plan, as well as a review of individual CM case files to assure that a plan is developed for each consumer in the program.

The Basics

This  requires that the case manager conduct (and, of course, document) a case management assessment for each consumer (patient, worker).  This assessment must be thorough, and will serve as the foundation for the Case Management Plan. 

URAC specifies the components of that assessment in the next standard.

URAC Accreditation Tips

The element requiring the conduct of the assessment is mandatory; the element requiring the assessment's findings to be documented is weighted 4.

Documentation should include a P&P describing the required assessment and the use of any tools in that assessment.  Screen shots of any automated assessment tools would be useful for submission to URAC in the desktop review portion of the application. 

The onsite review will be a through a review of consumer case files to see evidence of assessment for each consumer, as well as interviews of members of the CM staff to determine their ability to conduct proper assessments.

The Basics

This standard can be considered an elaboration of Core 28 (v. 3.0), which requires organizations to provide employees with tools appropriate to their jobs.  This case management standard adds specificity to the Core requirement, mandating that CM organizations provide data collection tools and care plan templates to their case management staff to collect information necessary to assess whether the CM program performance objectives are being met.

Management Tips

The key here is standardization of data collection elements in the data collection tools and plan templates.  Whether the tools and templates are online or paper, they must be readily accessible to case management staff members. 

It is insufficient to develop the tools; you'll need to develop clear descriptions about how each tool and/or template will be used. 

Keep in mind that the ultimate purpose here is to generate standardized data to facilitate program eveluation required by CM 10.

URAC Accreditation Tips

This standard carries a weight of 1.

For purposes of submitting to AccreditNet, the documentation should include:

• A description of the tools and templates, including copies or screen shots; and
• A description of how the data collected will be used for program evaluation.

The onsite review will focus on reviewing case files for evidence of use of these tools, and interviews and observations of the case management staff members to see how that use the tools and to assure that the tools are readily available to staff members.

The Basics

Under CM 19, the CM program must implement a P&P that requires case managers to obtain and document consumers' oral or written consent to participate in the CM program.  The P&P also should specify a time frame within which that consent should be obtained and the duration of the consent's validity.

Note to workers' compensation CM organizations:  Because many state WC laws assume consent, this is optional for WC CM programs.  

Management Tips

The P&P should define both a time frame for obtaining the consent and a length of time for which the consent is valid.  Additionally, if the P&P does limit the duration of the consent, it also should provide for a process under which the consumer may renew his/her consent.

This standard is not so harsh as to require consent in all cases.  It is rigorous, however, in requiring that, if the program does not obtain consent, that it has done this under an exception that it outlines in its P&P on consent.  

The P&P also should provide for consent from family members or other surrogates for the consumer if the consumer is unable to give the consent because of extenuating circumstances.  

URAC Accreditation Tips

The requirement for obtaining and documenting consent is mandatory; the other two elements are worth 4 points each.

Documentation, in addition to the P&P, should include a written consumer consent form and any education/disclosure information provided to consumers that reference consent.  

The onsite reviewer will verify compliance with this standard through her review of the case files. Therefore, it is imperative that the CM program's case files contain clear documentation of written and verbal consent obtained from each consumer, as well as any attempts to obtain written consent.  

The Basics

CM 18 sets forth five categories of information that the organization (typically via the case manager) must disclose to the consumer at the beginning of the CM relationship.  Four of the categories must be disclosed regardless of whether the consumer has requested it, while the fifth must be disclosed only if the consumer requests.

The four categories that must be disclosed regardless of request are:

• The nature of the CM relationship. This kind of information should include whether an insurer or TPA is involved.
• When and how information will be disclosed to others.  Again, this is to make sure the consumer knows whether an organization other than the CM program (e.g., insurer or TPA) is involve, and whether and when such organizations will have access to the consumer's information.
• The rules about written notification.  This disclosure should make clear the circumstances under which the consumer can expect to receive written notification about what is happening in his/her relationship with the CM program.
• The rules about filing complaints.  Echoing the requirements of the Core module's complaints and appeals requirements, this component mandates disclosure that is sufficient to empower the consumer to pursue complaints about the CM program's services.

The one category of disclosure that is tied to the consumer's request is the answer to the question, "why was the consumer selected for this program?"  This rationale might even include relationships between the CM program and other organizations, such as "your insurer, XYZ Co., identified you as being at risk for . . .."

Management Tips

Make sure the P&P gives clear guidance to the case managers about how to document these disclosures.

URAC Accreditation Tips

Each of the five elements of this standard is worth 4 points.

Documentation for this standard starts, as usual, with the P&P that requires the Program to provide this information.  In addition, though, URAC asks for the submission of documentation of implementation of the P&P, such as the "welcome packet" that some CM Programs send to new participants, or a "Patients' Bill of Rights."

The onsite reviewer will look for evidence of implementation of the P&P in both her interview of case managers and her review of the case files.  There should be clear evidence that the welcome packets, bills of rights, or other consumer notification documents  have, in fact, been sent to all the participants in the program.

The Basics

This standard requires that the CM program use a clear set of criteria to trigger the case management process for a consumer.  In other words, the program's P&Ps must clearly articulate how individuals are identified for participation in the program.   So, be sure to be familiar with how your organization's P&Ps do that.

Management Tips

This requirement of a clear set of criteria fo inclusion in the CM program applies even if the triggering event seems to be in the hands of a payer or other outside entity.  In many situations, such an entity has a contractual relationship with the CM program that describes a process by which the payer notifies the program of the identity of individuals who will be participants in the CM program.  In such situations, URAC requires that the CM program's P&P address this relationship.  

URAC Accreditation Tips

This standard is worth 2 points.

In addition to the applicable P&Ps, the CM organization also should submit a list of any contracts of the sort described, above, that trigger the case management process for an individual.

In addition to conducting the interview of case managers for their understanding of the criteria, the reviewer conducting the onsite review will examine case management files to assure that the criteria were properly and consistently applied to program participants.

The Basics

CM 16 requires the CMO to implement P&Ps that help it to assure that the health care providers and vendors to whom the case managers refer consumers are appropriate to the needs of the consumer.   Moreover, the case managers are obligated to implement the intent of the P&Ps and this standard, that is, to make sure that any time you involve a vendor in the care of a patient, you've given appropriate thought (and documented your thinking) about why that vendor is appropriate for this particular patient/worker.

Management Tips

The P&Ps should address how the organization monitors the performance of such providers and vendors.  That monitoring process should include a mechanism for case managers to report sub-standard performance by providers or vendors.  In addition, the P&Ps should describe the procedures for referring consumers to providers.

If the CM program is affiliated with a health plan or network, the P&Ps should deal with referrals to both in-network and out-of-network providers.

URAC Accreditation Tips

The standard has a weight of 2 points.

The P&P is the only documentation the organization needs to submit for purposes of the desktop review. 

The onsite review will involve both interviews of case managers about the referral process and evidence in the QM committee minutes that the quality of providers is a topic of discussion at QM committee meetings.  In addition, the reviewer will look for evidence of implementation of this standard in an applicable P&P or program description.