This CMS standard provides:

All MAOs that offer CCPs must ensure continuity and coordination of care through procedures for timely communication of clinical information among contracted network providers, with the member, and with his/her designees (if applicable).

The URAC standard implementing this is MAP-CCP2.

The Basics

This standard requires that your organization have policies and teachers to assure timely communication of clinical information among the members of your provider network, and between those providers and consumers and their families.  Those policies and procedures need to include:

• mechanisms to ensure that the organization on the network path sufficient information for quality continuous patient care and quality review;
• mechanisms for appropriate and confidential exchange of information throughout the network; and
• procedures to assure consumers have timely access to records and other information regarding their health and enrollment in health plan.

URAC Accreditation Tips

Documents be included with your desktop review submissions should include policies and procedures, the provider manual, sample provider newsletters addressing coordination of care, and the results of audits of medical records.  Member newsletters and education materials might be useful submissions, as well.

The on-site interview of the medical Director, utilization management and case management staff will include questions such as:

• What are the organization policies and procedures for care coordination?
• How are providers informed about the network care coordination services?
• Are member's medical records' audited?
• What items are on the tool ( follow-up care, education in self-care, health promotion activities, & referrals for care needs?)
• What education materials does the plan provide members to assist with coordinating their care?
• What requirements does the plan set for communication between the PCP and specialist?
• Are summaries sent to the PCP?
• A member is discharged from the hospital what is the expectation of the facility to inform the member of follow-up care needs?
• How often are enrollee member records audited?
• What policies and procedures are disseminated to providers regarding documentation guidelines?

A welcome message from Thomas G. Goddard, JD, PhD, Chief Executive Officer of Integral Healthcare Solutions, LLC:

The Basics

This standard, which is an extension of the Core module's requirement of a clear policy for handling consumer complaints, contemplates the very real possibility that your CM program is only one component of a larger set of programs within your organization, or that it works with/for other organizations.  What this standard adds to the Core requirements surrounding consumer complaints is that you have a documented process for distinguishing between complaints that relate to the CM program and those that relate to other programs in the organization or to other organizations with which your program works.  Once you have made that determination, your process needs to make sure that the complaint gets to the right place, i.e., that the CM complaints go to the person and/or process for resolving CM issues, and that the non-CM complaints a routed to the appropriate persons for the handling of such complaints.  In other words, make sure you have a process to assure that a complaining consumer is routed to the right person and doesn't fall through the cracks between the CM program and the rest of the organization.

Management Tips

Two examples may help to clarify this standard and help you write appropriate P&Ps for it.  First, assume your CM program is a component part of a larger organization, perhaps an insurer.  A consumer complaint comes in, and perhaps is routed by the customer service representative that takes the call to the CM program.  Your P&P needs to guide the person in the CM program on how to make sure that this is a CM complaint, how to handle it if it is, and where to send it if it isn't.  This easily can happen within integrated medical management departments that conduct both utilization management and case management (and perhaps even disease management) within the same office.  Make sure that you know how URAC sorts out this three functions and that calls are routed to the proper person(s).

A second situation might be that your CM program contracts with several plans or insurers.  Consumers may be confused about which organization to call with a particular complaint, and may call you instead of the insurer for a complaint about, say, benefits, which is more properly within the realm of the insurer.  Your P&P needs to anticipate that type of call, and guide staff members in your organization on how to handle the call.

URAC Accreditation Tips

So, in addition to your P&P, what documentation will URAC expect to see?  The best way to handle this would be through a well-constructed complaint log.  This log is no different than the one you'll need for the corresponding Core module standards, but the implication of this standard is that your log will have the capacity to distinguished CM-related calls from non-CM related calls, and track to whom the call was referred.  Also, if you have any correspondence, particularly in the form of template responses to complaints, submit these with your initial submission, as well.  

As you may recall, complaint and appeals reports need to be submitted to the QM committee.  So, it makes sense here to submit documentation that your reports to the QMC include the reporting of how these two types of calls have been handled during the reporting period.  

Remember, make sure everybody is trained on what your P&P says to do about these two types of calls, and that your documentation supports your assertion that you are complying with your own P&P.

The Basics

Not unlike URAC's requirements in the UM standards for concurrent review nurses, this standard requires that case managers working in the field:

• Carry clear identification (usually a name tag with a photo and the name of the organization);
• Either have an arrangement with the facility to be visited or give the facility a full business-day's notice of the visit; and
• Cooperate with the facility's procedures for visiting.

Management Tips

The intent of this standard, of course, is to make sure relationships between the CM program and the visited facilities are smooth and clear.  Agreements trump assumptions (and even this standard), so if you have a working relationship with a particular facility that is clear and, preferably, documented, that will govern case manager behavior.

URAC Accreditation Tips

Again, the key is documentation.  Have a solid P&P for onsite visits, and make sure you comply with that P&P.  If your visits are governed by agreements with facilities or facility P&Ps, make sure you have a record of those agreements and/or P&Ps.  

The program guide suggests that the reviewer may accompany a case manager on such a visit.  I'd be pretty surprised if that happened in the time-crunch world of a CM review, but it's a good idea to be prepared for that possibility.  More likely is the telephonic interview, in which the URAC reviewer will randomly select a field case manager to talk to about how she arranges her visits.

The Basics

Under this standard, you need to be familiar with your organization's P&P that describes the criteria you should use to decide whether and when to discharge a consumer from the program.  You should not only know your organization's P&P on the topic, but somewhere along the way should have received training on that P&P.  Finally, make sure you always document both the date of the discharge/termination and the rationale for that action.  

Management Tips

This standard requires the CM Program to do the following things:

• Write a P&P that describes -- clearly -- what criteria it uses to decide when and whether to discharge a consumer from the program, or terminate CM services to that consumer.
• Train the CM program's staff members on these criteria.
• Upon discharge or termination, record both the date of the discharge/termination and the rationale for that action.  The CM program should make sure that the documented rationale is consistent with the criteria outlined in the P&P.

As the program guide makes clear, URAC has expectations about this standard that are not embodied in the standard itself.  To meet those expectations:

• Make sure that the consumer is advised of the criteria early in his/her relationship with the case manager.  In other words, it should come as no surprise to the consumer that, when he/she meets her care goal, or returns to work, or in some other ways triggers the discharge criteria, that his/her relationship with the CM program will be ended.
• Notify all the providers of the discharge/termination.  The consumer's transition out of the CM program should be clinically smooth and safe.

As is always the case with URAC, it is not enough that you do these things, but also that you describe and require them in your P&P.

What if your clients set the criteria for discharge?  This is not uncommon, and it usually happens in the contract itself.  In this case, make sure your P&P allows for the possibility that the criteria in the P&P may be overridden by the policy established in the contract by the client.

URAC Accreditation Tips

The desktop review will focus on the adequacy of the P&P.  Further, if your clients do set the criteria, list the clients that do so and summarize the discharge criteria for each in a table that you submit to URAC.

The onsite review will focus, as usual, on interviews.  However, more importantly, the reviewer, as a part of her examination of case files, will check to make sure that the discharge criteria have been followed with your consumers.  

The Basics

This straightforward standard simply requires that the CM program implement P&Ps for dispute resolution within the program over issues concerning consumers' care options.  

This standard anticipates that reasonable minds within a CM program may differ about what is the best choice for a consumer's care.  It also anticipates that this disagreement could occur among and between any members of the CM care team, including providers.

Be sure to be familiar with your organization's dispute resolution mechanism.  Because URAC doesn't specify what it must look like, it is likely to be unique to your organization.

Management Tips

The standard isn't particularly prescriptive about what this dispute resolution mechanism should look like.  The program guide does hint at the possibility that the mechanism might lean on automated clinical decision tools, but other than that, it is mute on its content.

URAC Accreditation Tips

The initial documentary submission to URAC should include, as always, the P&P describing the mechanism.   The onsite review will focus primarily on interviews with CM staff at all levels, to be sure that the P&P has been implemented.  The reviewer is likely to ask questions soliciting examples in which the mechanism was employed to resolve in-house disputes over care options.

CM 20 carries a weight of 3.

The Basics

A question just came up -- does the requirement of ethics training apply only to case managers?  

On its face, the standard is clearly directed at case managers.  Many of the elements explicitly refer only to case managers and clinical and professional responsibilities.  However, while the focus of URAC's inquiry regarding this training will be on the Case Managers and their supervisor(s), the safer call would be to provide some ethic training to any non-case managers (as described in CM 6) who support the case management process.  The rationale for this is that URAC says that the scope of the standard is for "all case management personnel, and non-case managers are involved in the CM process and would have to be considered case management personnel.  However, because they have narrower responsibilities than a case manager, some aspects of this standard clearly would not apply.  So, you arguably could provide non-case managers with a narrower ethics training than the CMSA approach, perhaps one that simply dealt with:

• Prohibition of relationships that could compromise professional objectivity
• Disclosure of conflicts of interest 
• Prohibition of discrimination against a consumer or group of consumers

So, while you're probably ok with training just for case managers, a limited training on these limited topics would guard you against odd interpretations the occasional URAC reviewer. 

The Basics

This standard builds upon the CM assessment required by CM 18.  At its heart is the notion of collaboration between the case manager, the consumer, and members of the health care team.  At a minimum, the plan established by the case manager must set both short- and long-term goals, identify 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.

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 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

This standard carries 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 short, mandatory standard 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, which is the subject of CM 19. 

Although URAC doesn't specify in the standard itself what must be covered by the assessment, its interpretive materials make it clear that, at a minimum, the assessment should gauge the consumers current health and psychosocial status, his/her medical history and treatment plan, what resources may be necessary for appropriate case management, given the consumer's condition, and any safety issues that the case manager detects.  Other possible issues to include in the assessment might include how knowledgable the consumer is about his/her condition and what education might be required to fill in gaps in that knowledge, as well as any family or cultural issues that might bear upon the development of an appropriate plan.

URAC Accreditation Tips

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 tools and information to their case management staff to collect information necessary to the CM process and participate in the quality management process. Everybody involved in patient care, not necessarily only case managers, needs to have access to the appropriate tools and needs to be familiar with all the tools offered by the organization.

What kinds of tools are we talking about here?  They could be computerized tools for data collection, but also could be lists (providers and other resources), paper forms for gathering data, financial information, and case management plans.

URAC Accreditation Tips

For purposes of submitting to AccreditNet, the documentation should be a broad sampling of these tools, perhaps screen shots from computerized tools and copies of forms and lists.

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.

This standard carries a weight of 3, and all the elements are secondary.