URAC CM 7.0 Case Management Program (MM)

In this educational video, IHS's CEO, Dr. Tom Goddard, sits down with the company's Chief Clinical Officer and Senior Pharmacy Consultant, Sue DeMarino, RN, MSHS, CPHQ, RNC, to discuss the changes in the URAC Case Management accreditation standards to the new version 7.0.

Sue shares her insights and expertise on the updated standards, highlighting the key changes that impact case management organizations seeking URAC accreditation. She also offers practical advice on how organizations can ensure they meet the new requirements and maintain their accreditation status.

If you are a case management organization leader or compliance officer, this video is a must-watch! You'll gain valuable knowledge and a deeper understanding of the URAC Case Management accreditation standards and what it takes to achieve and maintain accreditation in today's healthcare landscape.

This video covers the case management program description; monitoring and evaluation; reporting and analysis of program performance metrics; screening and assessment process including medication review, assessment, and interventions; member case management plan development and ongoing monitoring; and case closure.

Watch more Case Management 7.0 video updates here.

Transcription

[00:00:24.820] - Thomas Goddard

Welcome back. I'm here with Sue DeMarino, Integral Healthcare Solutions Chief Clinical Officer. My name is Tom Goddard, the Founder and CEO of Integral Healthcare Solutions. In this video, we're going to talk about URAC new case management standards, version 7.0. From the medical case management side and just the segment of those standards that deal with the case management program. Sue, as we've already established as an expert on the case management standards at URAC, and we're going to talk first about what with respect to the medical case management program.

[00:01:05.720] - Sue DeMarino

Thank you, Tom. The first thing I'm going to talk about is the program development. Basically, you have to have a case management program description that identifies the goals and objectives of your program. What services are you going to provide and what geographic location? You're going to have to speak to referral criteria guidelines that are going to be used to determine who gets into your case management program or who is eligible to get into the program. We're going to talk about your case manager caseload and what's it based on? Is it based on acuity? Is it based on specific numbers? It may be based on the model of case management. If you're doing telephonic case management, the case management caseload can be much higher than if you're doing hospital-based case management where you're going there and you're visiting those patients who are either critically ill or injured from a workers' comp perspective. And case management is again another area that we'll talk about it and another recording related to workers' comp. We have to consider evidence-based guidelines. What is your program based on? How are you making determinations on what interventions and educational information you're going to provide?

[00:02:38.840] - Sue DeMarino

Again, looking at those evidence-based guidelines to help support and develop your program. What support tools do you have for your case managers? So, for instance, a standardized assessment, a standardized re-assessment, a standardized plan of care. The plan of care needs to be personalized, so you need to talk about how it's member centric. There has to be shared decision making in the program description that speaks to the mechanisms that you're going to put in place to help your patients and members have a say in the decisions that they're making. And of course, health equity, again, we spoke about that in an earlier recording. We're going to look at those patients who may be at risk for unplanned transitions. So how are you defining those patients? You're going to have to develop case closure criteria.

[00:03:41.260] - Thomas Goddard

Sue, if I could interrupt for a second. What might an unplanned transition be that an at-risk member might be at risk for?

[00:03:53.140] - Sue DeMarino

So let's say someone goes into the hospital, they get so debilitated that instead of going home, they have to go to a rehab facility. That might be an unplanned transition. Got it.

[00:04:07.950] - Thomas Goddard

All right. Thanks. Thank you for sharing with me.

[00:04:11.160] - Sue DeMarino

And then the plan also must address your case closure criteria. So when do you know a patient, a member should be discharged from the case management program? Is it when they reach a certain percentage of their goals? Is it when the case closure may be that the member no longer wants to be part of the program. There have to be defined performance metrics that you're monitoring. In addition to that, the program description has to identify the roles and responsibility of any committees that are involved in developing the program. You're going to talk about your program staffing. How many case managers do you need? Is it going to be based on acuity? Again, there's so many ways to staff. So, URAC is not prescriptive and what that should be, but it needs to make sense for your organization. And you can evaluate that through looking at your complaint data, your satisfaction data. The plan also has to define the re-assessment time frames. When you're looking at a member, when must that re-assessment occur? Is it after a transition that was unexpected? Are you going to re-assess that patient after they've been hospitalized? And then what reporting are you going to do?

[00:05:50.450] - Sue DeMarino

And you have to also specify that this annual evaluation that you're going to be required to do will also require you to report that to your leadership at least annual.

[00:06:05.400] - Thomas Goddard

Got it. This is very nearly 20, if I'm counting right, this is very nearly 20 specific items. If I know of URAC, they're going to want to, on their scoring tool, check the box for each one of these, nearly 20 issues as they review our clients' documentation. Is it your experience that our clients have this all in one big case management program description? Or do they typically break it up into pieces? And does URAC even care about that?

[00:06:39.940] - Sue DeMarino

Well, URAC doesn't care in what way you present the information as long as they receive it. I have seen organizations do it in one large program description, while others feel that they want the staff to be able to go to the specific topic if they want to look at a policy and procedure rather than search a large document and so they'll break it out. So it's organizational preference.

[00:07:06.860] - Thomas Goddard

Got it. Thank you. All right, moving on. Thank you for letting me jump in with my questions.

[00:07:12.730] - Sue DeMarino

No, that's great. And then let's talk about the monitoring and evaluation of your program. I made reference to it earlier and that being reported to the leadership annually. So again, the program description has to be reviewed and approved by the leadership annually. In addition, as part of that monitoring and evaluation, you have to look at your performance measures and evaluate how you're doing against your goals. You have to look at any corrective action plans that you've done in the year. You have to reevaluate the evidence-based guidelines to make sure you have the most current, relevant information on which to base your program on. And then based on your reports on what your case manager caseload is, you may need to tweak it. You may have gotten a new book of business that has more catastrophic cases. And so now you're going to have to reevaluate that caseload to allow for those catastrophic cases, which oftentimes includes visiting facilities, hospitals, even ERs. And then again, reevaluating the screening criteria that you put in place for who can be part of your case management services, and then again, that annual review of your discharge criteria.

[00:08:44.920] - Thomas Goddard

Now, I think it may be important for our viewers to understand that, Yurek, in standards that we're not covering in this series of videos, the foundational focus areas, what our longstanding clients know as the core standards, Yurek has recently changed the policy and procedure review requirement from annual to something longer than that. And so I think it's important to stress that this remains an annual review, even if the rest of their policies are being reviewed every two or three years. Is that right?

[00:09:20.790] - Sue DeMarino

That is correct. And I would point out that URAC has a glossary that they use when they're evaluating compliance—and annual is a defined term. In the interpretive information that URAC provides, they make reference to potential clients of theirs to go to that glossary and review it as you're looking at your policies and procedures. So the definition that URAC has for annual is month, year to month, year plus or minus a month or to the quarter. But your policy has to define which you're choosing, the plus or minus a month or to the quarter. My recommendation is always to the quarter. I think it gives you more flexibility. But as an organization, you'll need to evaluate what works best for you.

[00:10:11.350] - Thomas Goddard

And I want to underscore what you said there. If while URAC gives you the flexibility, you can't give you the flexibility once you've defined what your structure is. So if you say to the quarter, you can't bleed over into the next quarter. You've got to do what your policy says you do.

[00:10:30.950] - Sue DeMarino

Absolutely. Great point, Tom.

[00:10:32.920] - Thomas Goddard

All right. Because that's a whole different standard. You've got to implement your policies as a foundational focus area standard.

[00:10:38.810] - Sue DeMarino

Exactly. Got it.

[00:10:40.740] - Thomas Goddard

Now you had mentioned reporting and analysis of performance metrics in an earlier comment. Let's flesh that out a bit.

[00:10:47.400] - Sue DeMarino

Sure. What does URAC expect you at a minimum to report out on? Well, they want to report on the timeliness of your case management services. One of your metrics might be from when you get a referral till you enroll the patient or make contact with the member, what's the maximum amount of time that can be done within? And so then your are running reports to see, are you timely with your case management services? They're going to look at your case management caseload. What was your caseload in the previous year? Did you have a sufficient staff? So that might be part of that reporting and analysis. And then what is your member participation rates? So you have someone that you think is eligible, you reach out to them. Do they agree to case management or do they say, No, I'm not interested in case management? And then also member satisfaction with case management services. That is a very important distinction other than just satisfaction. Your survey has to specifically say that you are evaluating the satisfaction with the services that you have provided. So they're looking at that language.

[00:12:14.470] - Thomas Goddard

So does this impose on the case management organization an affirmative obligation to survey some members of the program, all members of the program? How does that work?

[00:12:25.600] - Sue DeMarino

Well, your policy will define how you're going to do it. Typically, what I see organizations do is they send out satisfaction surveys in the quarter following those patients that were discharged from case management. They then send out a survey. Other organizations, they do it verbally with the intake staff, the case management support staff. You have to be really careful there if you have a lot of different people doing it, because the way you present the question could the results. So if you're going to do it verbally, I would have a very defined script that staff cannot deviate from to be able to get that satisfaction information.

[00:13:10.900] - Thomas Goddard

Particularly because the staff member asking the questions might be the one who felt like they were being evaluated, right?

[00:13:16.400] - Sue DeMarino

Exactly.

[00:13:18.030] - Thomas Goddard

Yeah, sounds like a tight script would be good on that. All right, well, let's move on to the next section of these standards.

[00:13:25.490] - Sue DeMarino

Okay, the next section is all about the screening and the assessment process. So there must be a consent that is obtained, and it has to be documented. And then the patient needs to be appropriate for case management, so you have that screening criteria that you have. And then you must also document the referral source and rationale for selection in your documentation system. So again, you have to have documented consent. You have to document why the patient was appropriate for case management and who was the referral source.

[00:14:09.770] - Thomas Goddard

It's been a lot of years since I've done a review of case management standards, but I remember assessment being a really important part of the process. Can you talk a bit about that?

[00:14:22.450] - Sue DeMarino

Sure. You're right, Tom. It is a key component. The assessment, both from a physical and behavioral health perspective and the medication assessment are two of the main reasons why organizations are unsuccessful in their first attempt to achieve URAC accreditation. This is where usually the issues come in.

[00:14:46.430] - Thomas Goddard

That's what I recall.

[00:14:48.400] - Sue DeMarino

Okay, so in this version, URAC wants to know who are the sources of the information that's contained in that assessment. It could be the member, it could be their caregivers, it could be members of the healthcare team. You may be getting the information from medical records, claims data, and in today's day and age, the electronic health record.

[00:15:11.180] - Thomas Goddard

So you have to- I'm guessing it's really from most, if not all, of those, right?

[00:15:16.170] - Sue DeMarino

Sure, it could be. And in order to get answers so you could run reports, look for trends, you need to have standardized tools. So standardized tools for your assessment. I also recommend having a standardized tool for your re-assessment and plan of care. I will tell you, when organizations depend on case managers just to remember to ask a certain question and write it in their notes, they are often unsuccessful. And that is probably, like I said, one of the reasons why organizations are not successful.

[00:15:57.040] - Thomas Goddard

And of course, this has nothing to do with case managers. It has to do with humans. We've seen this in the pharmacy world because the pharmacy standards require an assessment in the specialty pharmacy world and all over the healthcare world. Humans can't remember the complexities of what they're required to assess. We've got to standardize the tools.

[00:16:20.290] - Sue DeMarino

Oftentimes, case managers are being pulled in multiple places. They're doing an assessment or documenting assessment. They may have a crisis call, they may have a support person who needs them and may be pulling them away from the documentation and they lose their train of thought. Heaven knows I've done that a few times. So what do you have to evaluate for a medical case management case? Well, you have to look at the member's medical conditions, medical status, I should say, cognitive status, whether there are any behavioral health issues, including substance use and abuse, VOTE, like where do they work? Do they have a job? Functional assessment and social determinants of health.

[00:17:12.970] - Thomas Goddard

I'm imagining, Sue, that even if they don't have one of these issues coming up, the case manager has to record the negative. In other words, if there are no social determinants of health that are worth noting, the case manager probably has to make note of that, right?

[00:17:32.560] - Sue DeMarino

Right. Well, they have to make note of any barriers to getting the information. And we'll learn a little bit later that if there is a section that has never been addressed during and the patient is now ready for discharge, and so it's a closed case, and URAC reviews this record if, let's say cognitive is never addressed and there's no documentation on why, URAC will mark that as out of compliance. Right. Okay. Certainly you can defer something for a later date, but then you have to have follow-up, and that follow-up has to be documented.

[00:18:13.950] - Thomas Goddard

It sounds like it might be hard to do, though, to make sure that you follow up other systems to make sure that if you don't address it now, you'll address it later?

[00:18:25.030] - Sue DeMarino

Yeah. They should be entering a calendar note of when they need to do that follow-up. And sometimes it's helpful to almost make an appointment with the member to do this because this will take a little bit of time if you're going to do a complete assessment. Organizations can define with the first contact what must be done in that first contact and then do a later section at the next contact. But again, your policies will define that process.

[00:19:02.360] - Thomas Goddard

Right. And your systems.

[00:19:04.160] - Sue DeMarino

Will define that. Exactly. And the other thing that they want to know is whether the member or the caregiver is interested in being involved in this process, like in developing the plan of care, what their preferences are and things like that. So again, was the member and/or caregiver involved in the obtaining of this information? And then what resources are available and needed, may be needed for the member? What provider options do they have? And do they have sufficient available benefits? And then the one that makes me smile is the last that I'm going to mention, and that's the members ability to engage with digital health resources. It is a leading indicator, though. So basically, in today's day and age, if my mom was still alive, the answer to that would be absolutely not. She had no interest in anything to do with the computer or technology. So now, Yarek is moving organizations to start evaluating that by making it a leading indicator, which is an optional standard. So you can choose to meet it or not meet it.

[00:20:24.970] - Thomas Goddard

Frankly, I must confess, I'm a bit surprised it's only a leading indicator at this point because it would be very easy, it seems to be, in the 21st century to presume that everybody is comfortable with digital access when, as you and I know, not everybody is.

[00:20:41.300] - Sue DeMarino

Exactly.

[00:20:42.220] - Thomas Goddard

All right. Let's move on to medication assessment.

[00:20:45.400] - Sue DeMarino

All right. The first thing you're going to look at, as you are evaluating the patient based on the assessment that you're going to do, are there goals needed to be placed on the plan of care? Does there have to be... It must be part of the plan of care that you have for this patient. What do you have to do for the medication assessment? I always call this standard the medication safety assessment because you're evaluating a number of things. Does the patient understand their medications, why they're taking it, how to take it? Are they adherent? Are they missing any doses? Is there a history of substance use disorders? Do they have a current med list? And that includes over-the-counter meds, biologics, or herbal supplements. That includes all of that. And then do they share that med list with their providers? So they may have three specialists and a PCP. They should be sharing that med list so there's no duplicative therapies being provided. And do they need a medication reconciliation? If the patient is non-adherent, if they don't know what their meds are for, if when you look at that med list, you see that there are three narcotics and an analgesic, well, I'm guessing that they need a med reconciliation.

[00:22:17.690] - Sue DeMarino

Or do they need medication therapy management services? And if you're part of a large health plan, you may already contract with an MTM service. And this does not mean that the case manager needs to do the medication reconciliation. They can facilitate it. They can make that referral to a pharmacist. If you have a pharmacist as part of your case management program, or they can make a referral back to the PCP saying, Hey, this patient has duplicative therapies. Here's their med list. So you've done what you were supposed to do as a case manager. Now, as I mentioned a few moments ago, if the standard will be marked not met, if the assessment is deferred and there is no follow-up documentation, or if the case is closed and an assessment category has never been addressed, even to document why it was not relevant to the case. Now, again, a couple other things that Yrek wants to see documentation on, is if the member failed to participate in any part of the medication assessment and any barriers, if the case manager is unable to get a complete med list. Those things need to be documented.

[00:23:45.590] - Thomas Goddard

Got it. I think the next section of the standards goes to how the case management plan is developed and the ongoing monitoring of that plan. Would you care to take that on?

[00:23:58.940] - Sue DeMarino

Sure. Well, again, a member-centric case management plan has to be developed in collaboration. It could be with all stakeholders. You need to consider the members' needs, their capabilities, and their preference to participate. So you need to have a way to document whether they were agreeing to participate. So as you're looking at your system, the more you can put into your system as click boxes or check marks, the easier it will be for you to run reports. And then you have to add documentation if a member disagrees or refuses to participate in the development of the plan of care. Those are some key pieces related to the member case management plan. Now, what's included in the plan? What do you have to have? Well, you have to have measurable, short and long-term goals. You need to identify time frames in which you think you will be able to reach those short and long-term goals. And you have to have interventions to help the member get there. So what does measurable mean? It's usually a number, a ratio. You can't just say the pain will be improved. You need to say that your baseline of pain on a scale from one to ten is four.

[00:25:18.540] - Sue DeMarino

You want to get to six by two weeks. So again, you have to make them measurable. And URAC will evaluate whether they are measurable or not. Could do points deduction if you have a goal that is not measurable. You have to identify any education and resources that may be needed for the member to promote informed decision making by the member. You have to identify your progress toward goals. So how do you do that? By re-evaluating the plan on a periodic basis. So what I tell folks to do is calendar your next call with the patient. And so it gets on your schedule and then update the plan of care every time you have that goal, have that call to say, are they falling short of the goal and may need additional education interventions? And so then you would update that plan of care. You need to identify the frequency of communication. You have to identify the preferred method of which you're going to make that determination. So you might base it on acuity level. You may base it on educational needs, how often you're going to break it down. Because if you have a brand new diabetic and there's so much to learn, you don't want to give them all that information all at one time, you're going to break it up in segments.

[00:26:55.160] - Sue DeMarino

So you may need to evaluate how much that patient can learn in one sitting or how available their caregivers are in order for you to do that training that may be needed. And then you need to identify any preferences and values related to health and human services. I would hope that I could say in today's day and age that behavioral health issues are not... There's no stigma to them. But in today's day and age, and I know that's not exactly true. So this is where you're evaluating that member's preference and their values related to that area so you can communicate with them in a way that's not going to cause them to shut down.

[00:27:48.580] - Thomas Goddard

Now, as I understand the standards, we move to the monitoring of the progress of the management plan.

[00:27:58.750] - Sue DeMarino

Yes. You're going to reassess that plan of care. Again, you're going to define it. It's going to vary. What I see most organization is identify a maximum amount of time that you can wait to do the re-assessment. It must be completed at least quarterly. I'm just throwing that number out there. But you may find that you need to do it more often when you do your contact with that member because something new has come up. And that plan of care, the goals you may have set for that patient and with that may change as that patient's condition changes. You may have to prioritize something else. If all of a sudden they've lost their job and they don't have a place to live, well, there may be a different goal for that patient. There may be different interventions you're going to put in place because someone who is homeless is not going to want to worry about some other area. They're going to be concerned about the safety, if it's a safety issue. And then is a revision needed? Is there ongoing collaboration? And then are you monitoring for any transition of care and information that you have to provide for that patient?

[00:29:16.340] - Sue DeMarino

As you're looking at the case, as you're evaluating the member's progress, do you anticipate a transition of care and what information is available? How are you going to help that patient transition? Got it.

[00:29:32.730] - Thomas Goddard

Well, what's next in these standards?

[00:29:35.040] - Sue DeMarino

So next we're going to talk about closing the case, the case management case. And I will tell you, I often say that in utilization management, you often get many complaints. But in case management, not so much, because you are helping this patient or this member get somewhere. And sometimes you're the only contact that the member has a regular contact that they can address their health care concerns. So they can't wait for your call. And so you don't get as many cases. So sometimes case managers want to hold on to a case because they built a relationship with that patient, especially those oncology patients that you've had for a long time or a catastrophic case where you may have been managing for a year. So you build that rapport. But no matter... So you have to have case closure criteria identified, and you have to document things at case closure. What was the status of their goals and outcomes? Did they meet? Were all goals met or some partially met? You're going to document that. Do they need any referrals? Are there any barriers to closing the case management services for this patient? And then finally, what is that closure rationale?

[00:31:02.730] - Sue DeMarino

You're going to actually document that closure rationale. And finally, how are you communicating that you're closing case management? Well, your ex says it can be verbally, it can be in writing, but it needs to include, if needed, any post-closure referrals and any post-closure resources and any plans for transition of care.

[00:31:28.320] - Thomas Goddard

That's great. These are... This has been a great review of the medical case management standard as it relates to the case management program. That's the end of this recording. We're going to have a totally separate recording for the workers' comp version of the case management program standard requirements. Sue DeMarino, thanks so much for doing this video with me. And as always, if any of our viewers have any question, you can reach out to us, have a conversation with Sue or about these standards or about any help you may need as you take on version 7.0 of the URAC case management standards. Thanks, again. Thank you.