URAC CM 7.0 Case Management Staff Qualifications, Training and Responsibilities (QTR)

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.

Topics covered include: professional Case Manager credentials and competencies, and how to evaluate competencies; professional Case Manager orientation and training; supervision of professional case management staff including certification and other requirements of the supervisor; and roles and responsibilities and training of case management support staff.

Watch more Case Management 7.0 video updates here.

Transcription

[00:00:27.100] - Thomas Goddard

Greetings, and welcome to this installment of our review of the URAC case management accreditation program, version 7.0, relatively new to us as we're recording this video. Today, we're going to focus on the case management program, but specifically for workers' compensation case management organizations. I'm joined today by Sue DeMarino, who's Integral Healthcare Solutions Chief Clinical Officer. I'm Tom Goddard. I'm the Chief Executive Officer. Sue, welcome. Thank you for joining me today about this workers' comp case management program discussion.

[00:01:08.030] - Sue DeMarino

Thank you, Tom, for inviting me.

[00:01:10.230] - Thomas Goddard

Let's dive right on in and talk about program development, how the workers' comp case management program develops its program, and what has to be in that program.

[00:01:21.580] - Sue DeMarino

Sure. Well, the program development requires that you have a program description, and that program description needs to include things like your goals and objectives of your program, what is the scope of your services and those activities related to the scope of the services. So in this instance, we're talking about workers' comp. So you may want to speak to whether Vogue Rehab is part of the services that you're offering as an example. You have to identify those referral guidelines or criteria, like who can make a referral to you? Can an injured worker self-refer? Does it have to come from an employer that you're contracted with? And then what criteria do you have in place that govern the case manager caseload? Is it based on acuity? Is it based on a mix of both catastrophic and non-catastropic cases?

[00:02:24.680] - Thomas Goddard

I can imagine that that piece of the program description is also intended to serve as a tool for management to figure out if they have sufficient staffing. Would you say that's fair?

[00:02:36.400] - Sue DeMarino

I would say that that was absolutely spot on.

[00:02:38.980] - Thomas Goddard

Got it.

[00:02:40.800] - Sue DeMarino

Then you have to evaluate what you're going to base your program on. And there's a requirement that you use evidence-based and/or state-specific treatment guidelines. Oftentimes, the regulators will guide specifically what your program needs to look like. I will tell you, if the regulatory requirement is tighter than the URAC requirement, URAC holds you to whichever is tighter of the two. That's an important concept to understand. So again, if those jurisdictional requirements conflict with the URAC standards, the organization must follow the more stringent requirement.

[00:03:20.890] - Thomas Goddard

And that's just a specific application of a general rule across not only across these standards, but across all of URAC. If there are two sets of standards, URACs and state regulators, or even clients, it's the more rigorous of those standards for the organization that must be complied with. So this is just specific to this piece of it.

[00:03:47.010] - Sue DeMarino

Yes, absolutely. And then you're going to identify the clinical decision support tools that you're using. You're going to talk about having a personalized case management plan. Oftentimes, though, you have in workers comp, if the patient is represented and there's attorneys involved, they may not be permitted to talk to you. And then that's something you have to make a note of. That's something you need to address in your program description how you're going to handle it. Because remember, URAC definition of case management includes that it must be member-centric. They have to be involved in the process. So instead of doing case management, you may be doing behind-the-scenes care management. And how do you differentiate those two? You need to speak to care coordination principles that you're going to use. You have to include information on a return-to-work assessment. Who does it? When is it done? And then any transition of care that may be within the scope of the services that you're providing. What happens if it's an unexpected transition of care? How are you helping that injured worker get to that next level? And then what criteria are you going to use to discharge that injured worker from case management?

[00:05:14.480] - Sue DeMarino

So you have to have clearly defined criteria. You also.

[00:05:19.320] - Thomas Goddard

Have to define performance measurements. Do you not in these?

[00:05:24.370] - Sue DeMarino

Yeah, we're going to talk about that.

[00:05:25.860] - Thomas Goddard

Okay, sorry about that. Please go ahead.

[00:05:28.800] - Sue DeMarino

And then you also have to define those performance measures, as you led me into, Tom, thank you. And the roles and responsibilities of the committee, what are they supposed to do? What are they responsible for? You have to identify your program staffing requirements. You mentioned a few minutes ago, Tom, about the criteria caseload. Yes. Again, to your point, that will help define that program staffing requirements. Reassessment time frames, we talked about that. We'll be talking about that in a few minutes, related to the care plan and the assessment, doing those reassessment at specific intervals. And then what type of program reporting are you going to have? Some of that may be governed by the regulatory body. And then this program description must be reviewed and approved by leadership at least annually. And as you may or may not know, URAC has a definition of annual, and we want to make sure that you are getting the benefit of that definition. So URAC defines annual as month, year to month, year plus or minus a month and/or to the quarter. My recommendation is always to the quarter. I think that gives you a little more flexibility.

[00:07:05.290] - Sue DeMarino

And so that would be my recommendation. But then your policy needs to define what annual means to you.

[00:07:14.050] - Thomas Goddard

And whatever you do, you've got to follow whatever your policy says. Even if you've chosen one of the more lax approaches in terms of defining annual, whatever your policy said then becomes the law. If you're violating that, you're violating an entirely different standard. And the.

[00:07:32.280] - Sue DeMarino

Other thing you need to consider is that injured worker or claimant may have limited rights and that other stakeholders may impact your decision making. So you need to take that into consideration. Those other stakeholders might be third-party administrators, adjusters, attorneys. As I said, if you're not permitted to interact with that attorney, that may impact how you do the... Whether you do case management or care management.

[00:08:02.160] - Thomas Goddard

Got it. If I'm counting right, there are about 18 different components to this workers' comp case management program description, including the return to work assessment. The... URAC, as I understand it, and correct me if I'm wrong, Sue, will look for all 18. Their tool, when they're checking off whether you've got it in one big document or various little documents to make sure that every one of these 18 items required by the standards are in your program description. They're enforcing that pretty rigorously, are they not?

[00:08:44.630] - Sue DeMarino

That is correct, Tom. You need to address it.

[00:08:49.330] - Thomas Goddard

They've got a checklist, so you need a checklist.

[00:08:52.040] - Sue DeMarino

Exactly.

[00:08:53.340] - Thomas Goddard

Got it. All right, so let's move on to monitoring and evaluation.

[00:08:58.650] - Sue DeMarino

There has to be documented monitoring and evaluation, at least annually, of how your program is doing. What has your performance shown in the last year? Did you need to put in place any corrective action plans or based on the evaluation that you're doing, do you need corrective action plans? You have to, again, evaluate what evidence-based or state-specific guidelines you're going to use within that program. You need to take that into consideration as you're monitoring and evaluating that program. Then again, that case manager caseload. Again, thinking about metrics that you might put in place or performance indicators that you might put in place that will help you meet the intent of doing this monitoring and evaluation.

[00:09:57.040] - Thomas Goddard

I see something in the standards here about screening criteria. That also applies to the workers' comp?

[00:10:03.940] - Sue DeMarino

Yes. They have to have screening criteria. Absolutely. They have to define that.

[00:10:08.870] - Thomas Goddard

They have to review as a part of their annual review of the effectiveness of the program, whether these screening criteria work. How is that done typically?

[00:10:19.290] - Sue DeMarino

The evaluation of the screening criteria? In some jurisdictions, you are not required to put the referral reason, but in areas where you have that information, that is what you are evaluating. You can also look at what percentage of patients actually opt in to the case management process, and that might be an indication of your screening. If your number is too low, you may need to reevaluate your screening information.

[00:10:54.030] - Thomas Goddard

Got it. Right.

[00:10:56.870] - Sue DeMarino

The next section deals with reporting and analysis of your performance metrics. Again, you need to analyze the data and report the outcomes to your leadership, and it needs to include timeliness of workers' comp, case management services, case management caseload, what percentage of your claimants or injured workers have returned to work, and then the satisfaction of those injured workers, family members, caregivers with the services that you have provided. This can be a standalone report, or you can do it as part of your Q. M. Program evaluation, but addressing it that it's covering case management.

[00:11:44.840] - Thomas Goddard

And so long as it's reported to leadership, that's an important key to this standard.

[00:11:49.510] - Sue DeMarino

Absolutely. You may have leadership on your quality committee that it might be a little easier to get an audience with them, depending on the levels of separation between those that write the report and lead the department and the leadership team.

[00:12:06.740] - Thomas Goddard

Right. Got it. All right, well, let's move on to screening and assessment.

[00:12:11.620] - Sue DeMarino

Okay. Again, in workers' comp, case management consent is often presumed, and you may not have to obtain a consent, but you need to state that in your policy and procedure. If the jurisdiction does not presume consent for case management, then you have to document the consent.

[00:12:37.460] - Thomas Goddard

Is this very widely from state to state in your experience?

[00:12:41.190] - Sue DeMarino

I would say it can, but typically, URAC gets a lot of Ohio BWC case management organizations or the MCOs, and their consent is to resume. It just depends on where you're at in the country.

[00:13:03.720] - Thomas Goddard

Got it.

[00:13:06.010] - Sue DeMarino

Then you need to document the referral source for the workers' comp case management services part of that screening process.

[00:13:13.610] - Thomas Goddard

Got it. That's the screening. How about the assessment piece of these standards?

[00:13:22.150] - Sue DeMarino

I do have one other point to make, though, that I failed to mention earlier to you, Tom, when we were prepping. That is that some state workers' comp laws requires you to participate in case management. If they fail to, they may not receive services. They may not get reimbursed for the services that are related to the injury that they received at work. I just wanted to make that point to make sure that organizations address whether that's the case in their program description.

[00:13:58.740] - Thomas Goddard

Right. That may not be in the URAC standards, but it's certainly a legal requirement in certain states, from what I understand you're saying. Got it. All right, now moving on to assessment.

[00:14:09.180] - Sue DeMarino

Okay, again. Now we're going to talk about whether the injured worker, are they involved in the process of case management? And then how do they identify themselves? Do they consider this a burden? Do they consider it their right? Again, thinking about their mindset there. And then collecting information from multiple sources you need to identify where you're getting the information. Are you getting it from the injured worker? Are you getting it from their family, their providers, from the facility or other members of the healthcare team? You may be getting it from clinical records, the physician's treatment plan, if it's available to you. You have to review information in accordance with, again, those regulatory requirements, policy requirements. I can remember when I first started doing workers' comp case management, I was looking at a policy a URAC applicant sent in, and they kept talking about a FROI, and I kept scratching my head thinking, Oh, what could this possibly mean? Then when I realized it, I've never forgotten it. It's the first report of injury or illness. You'll hear me talk about FROIs now because I feel like I know a little bit about the lingo.

[00:15:41.340] - Thomas Goddard

You're a FROI expert.

[00:15:42.450] - Sue DeMarino

Got it. Yeah, I'm a FROI expert.

[00:15:44.260] - Thomas Goddard

Yes. That's a pretty narrow niche, too.

[00:15:47.120] - Sue DeMarino

Exactly. Then the injured workers' perception of what their healthcare needs are. How do they feel about what they need? Then you need to also review the claims and administrative data. Then if you have access to the functional capacity evaluation that's often done in workers' comp, do you have access to that? That should be reviewed. You should be looking at a job analysis and a job description if it's available to see what work they need to do, and are they capable of doing that work? Like if they have to do a lot of lifting and they've had an injury to their arm or their muscle area related to lifting, that they may not be able to do that job at the current time. And then you may or may not be familiar with independent medical vows, their IMEs. So if that's available for you, then you would take that into consideration and review that information. And then oftentimes the customer will provide instructions to you or there'll be account guidelines that you need to take into consideration.

[00:17:07.830] - Thomas Goddard

Ideally, though, it sounds like this information not only can but should come from multiple sources. So you're getting it from all these sources. You have a full, well-rounded picture of the situation both with the worker and the setting that they're hoping to return to as a worker.

[00:17:26.780] - Sue DeMarino

Great summarization. Thank you, Tom. You bet. So you need to use a standardized tool. You have to evaluate the history of their present injury or their disability. You have to also take into consideration any medical, cognitive, behavioral health issues, because that may impact the ability of the injured worker to recover from whatever the injury or illness is. Whether there's a substance use disorder, vocational, if they no longer can do the same job, they may need vocational assistance, functional and social determinants of health. Oftentimes, I speak to looking at social determinants of health almost immediately because that may impact the ability of the injured worker to even be able to comprehend what you're talking about. For instance, if someone is now homeless and they're not going to be able to hear what you're saying because they're going to be so worried about finding a place to be safe. Then the assessment process should include the involvement of the injured worker and maybe the family or other caregivers as needed. Any available resources that may be needed? Does the injured worker have provider options? Sometimes that's regulated by the state on what providers they can go to.

[00:18:59.330] - Sue DeMarino

Then do they have access to those services? Then you will need to do an initial and then a subsequent re-assessment as required by the plan of care that you're going to put in place. Got it. Then one new requirement that I smile at is it's a leading indicator, an optional standard that says that you assess the injured workers' ability to engage with digital health resources and services. I would like to say that that's a given in today's day and age, but sadly, I do not believe that to be the truth. Would you agree, Tom?

[00:19:40.150] - Thomas Goddard

It is certainly not universally the truth, which is why it surprises me a bit that this is only a leading indicator. If I were a King of URAC, I'd probably say we need to know, because if we assume that everybody has moved into the 21st century, we're liable to leave a worker out of this process. We better assess this just because you're actually just fired up.

[00:20:10.200] - Sue DeMarino

All right. Let's go on to the medication review, assessment, and interventions. I have often said that this area, along with the assessment area, is usually the reason why an organization is unsuccessful in either obtaining or maintaining their URAC accreditation.

[00:20:31.030] - Thomas Goddard

I'll say when I first started doing case management reviews before you joined us, I remember being very impressed with how central the medication assessment piece of this was. Let's flesh that out a bit for our viewers.

[00:20:48.440] - Sue DeMarino

Okay. Well, one of the things you're going to do on the initial and any other re-assessments that you do, you're going to determine whether you need to put goals in that plan of care related to that medication safety or medication management. So what do you need to evaluate? Well, you need to evaluate whether the injured worker understands the meds they're on. And that includes those opioids, biologics, it also might include over-the-counter, herbal meds. You need to evaluate adherence. Are they taking their meds? Do they have any allergies? Are they having any side effects that would all be part of that medication assessment? Do they have a history of a substance use disorder? Oftentimes when there are injuries, they are prescribing opioids, and you want to make sure that someone with a substance use disorder that the provider is aware. You want to make sure the injured worker has access to a current med list, including those vitamins and herbal supplements. And do they share that med list with all their providers? So they may have a PCP, but they may also have three or four specialists, and if they're getting medications from all, they should be sharing that med list to prevent duplicative therapy or contraindications.

[00:22:18.690] - Thomas Goddard

It's always struck me that this is one of the central values of case management list, is to help pull together a variety of case management of the providers involved in the management of an injured worker's health? Because they're not necessarily doing that, especially... And not even the PCP is necessarily doing that, right?

[00:22:42.010] - Sue DeMarino

Right. You need to evaluate whether medication reconciliation is needed. So if they don't understand their meds, they're having side effects, they have duplicative therapy or cumulative where adverse events could be happening because they're on a couple of different opioids and other meds that may impair ability to function. So maybe a med reconciliation needs done. That doesn't mean the case manager needs to do the med reconciliation, but at the very least, they should be making a referral to either a pharmacist back to the attending or another clinician looking at what resources your organization has for medication reconciliation. Then whether there's a medication therapy management services are needed. Again, part of that medication review assessment, need for MTM services, need for med reconciliations. And then you need to be able to support interventions to include medication access. Can they get the medications? Can they get them safely? Are they adherent to therapy? If they're not adherent to therapy, what type of education will you do to help them become adherent? Take the medication with an activity of daily living. Take it on days where they have routines, having alarms on... We all have smartphones today, or most of us do.

[00:24:17.150] - Sue DeMarino

You can put timers and reminders to take your medications. And then is the injured worker independent in their medication management? How are you going to help support that independence? Then another intervention might be that the injured worker collaborate with a pharmacist, and then making those referrals for those medication-related services, which we mentioned before, med reconciliation and MTM services. If you are governed by a regulatory body, they may have MTM services contracted. They may have folks that will do med reconciliations. You can refer them back to the pharmacist who did a feel at their local pharmacy. One thing I wanted to just tell you a little bit about, and that is if at close of case, if URAC finds during the file review that you have a section, a category, an assessment category that's never been addressed, even if you just document that it was not relevant to the case and why, if it's never addressed and you have no documentation, URAC would consider that case not met.

[00:25:47.900] - Thomas Goddard

Same way- This is the push me, pull you thing. Sometimes the assessment has so much, it's hard to do in one thing, so you might postpone it. But you got to make sure you've got a system so that you don't postpone it indefinitely so that it never gets done. That sounds like a really important thing that you've just raised. Thank you.

[00:26:12.030] - Sue DeMarino

It may be that the whole assessment is deferred. And if there's no follow-up, like the injured worker might say, I have a doctor's appointment, this is not a good time. And if there's no follow-up documented that you tried to complete that assessment, URAC will mark it as not met.

[00:26:33.980] - Thomas Goddard

Got it.

[00:26:35.300] - Sue DeMarino

Or non-compliant.

[00:26:37.510] - Thomas Goddard

All right. Well, let's move on to the case management plan development piece and the member case management plan. Let's talk about that a bit.

[00:26:44.880] - Sue DeMarino

Okay, so you have to have an individualized case management plan. There has to be collaboration with the injured worker and maybe the injured worker is not available. And so you collaborate then with family, caregivers. You might even have to go out to other stakeholders that are part of the multidisciplinary care team. And you have to address some very specific things. You have to document any disagreement or nonparticipation by the injured worker and the actions that are being placed in that plan of care. And then, excuse me, interventions based on the treatment plan need to include input from that injured worker. So they have to be part of, they have to collaborate on that plan of care. Okay? And you're going to talk about medication management, desired outcomes for allowed conditions, in addition to short and long-term goals that are measurable. What do I mean by measure? There has to be a number, a ratio, a percentage tied to it, or a distance. If you're using a scale for pain, what was the baseline? Did the patient start out at pain with 10 being the worst and he's at 10 and you wanted to come down to three within a certain period of time?

[00:28:08.990] - Sue DeMarino

That's what makes it measurable. If they're unable to walk, if they're walking five feet now, where do you want them to get to? Is it 15 feet in a week or a month? And then what health education and information do you need to help provide to this injured worker so that you can promote informed decision making, that the injured worker has some input into the plan of care. Studies have shown that if you have injured worker or member involvement in a plan of care, you're more likely to achieve the goals because they have input into it. They feel like they have a piece of the pie, basically. And then what is their progress to return to work? Because at the end of the day, I'm betting that your long-term goal is either same job, same employer, same job, different employer, or different jobs, same employer along those lines. That's usually the long-time goal always is returning to work. And then the short-term goals are the steps that will get you there. And then the plan to further communicate on that plan of care to get updates from that injured worker and the frequency. And how does the injured worker want to receive that communication?

[00:29:40.300] - Sue DeMarino

Do they want you to call them? Do they want email? Do they want you to use texting? And does your organization then require consent for the texting and the email communications?

[00:29:55.860] - Thomas Goddard

I would think that this is not unlike the whole you've got to follow your policy requirement we talked about earlier. You really have to follow your plan requirement. So if you and the injured worker agree that you'll communicate every month by email, the documentation for that case better demonstrate that you communicated to that injured worker by email. Is that how you're interpreting that?

[00:30:23.050] - Sue DeMarino

There has to be the communication. You can identify. I don't think on every note you have to say it was an email, but you have to have documentation of that communication that you communicated with this injured worker and this was discussed and this was what was agreed.

[00:30:38.260] - Thomas Goddard

And at the frequency that you all agreed on it and documented in the plan. Got it.

[00:30:43.230] - Sue DeMarino

And if you can't meet the frequency, what's the barrier to meeting that frequency turnaround time?

[00:30:48.420] - Thomas Goddard

Good point.

[00:30:49.200] - Sue DeMarino

And then again, when you're building the plan of care, and I'm betting that you may have some templates for your plans of care given very specific injuries, and make sure that you're using evidence-based guidelines and any state-specific treatment guidelines to help build those plans of care. Okay?

[00:31:17.750] - Thomas Goddard

All right. Then I would think the next piece of this, of course, if I'm reading the standards right, is monitoring the progress through that plan.

[00:31:27.570] - Sue DeMarino

You're going to do ongoing review and assessment of those goals against that injured worker's progress. You're going to look at ongoing collaboration, communications with that injured worker. You're going to make revisions to the care plan as things change. The goals that you may have set after the initial assessment may change altogether, depending on how the injured worker is doing. You may have to come up with a whole new set of... Prioritize a whole new set of goals and the associated interventions. And then you need to plan for transitions of care and what information you're going to provide to that injured worker. I think.

[00:32:14.050] - Thomas Goddard

We're in the home stretch here. We're going to close out this conversation today with, appropriately enough, the closure of the case. Take it away, Sue, about how to close a case and what the workers' comp case management organization needs to do around case closure...

[00:32:30.900] - Sue DeMarino

Okay, so again, you need to have criteria for when you close the case. And some of that may be regulatory directed to you. It may be contracted language. It may be an organization decision. So whatever that closure criteria is, the case manager needs to be evaluating the injured workers progress toward whether they're close to meeting those closure criteria. But now that let's say that they have, so then what do you need to document in the records related to that case closure? Well, you have to document their return to work status. Did they reach their goals? Did they get to the outcomes that you had set for them that you expected to happen with the interventions and the goals that you put in place? And then do they need any further referrals? Do they need any community support? Do they need behavioral health, social service? So then that would need to be documented. And then of course, what that rationale was for closure. And then was there any barriers at closure that related to the closure of the case management services? So what was that resolution of barriers and what were the concerns that were raised and how did you resolve them?

[00:34:04.290] - Thomas Goddard

And then, of course, the injured worker needs to know about the closure and needs to know something about the closure. So let's talk very briefly about the communication of the closure to the injured worker.

[00:34:14.600] - Sue DeMarino

So again, you'll have to look at the stakeholders. In workers' comp case management, they always talk about the three-point contact, and that includes contacting the injured worker, the employer, and provider. And so you may need to notify all of these stakeholders regarding the closure. And that notification can be verbally, it can be in writing. And then if it's applicable to the closing of the case? Are there any post-closure referrals that will be needed? How would they access that referral information? What resources might be needed post-closing the case? And any potential plans for transition of care?

[00:35:03.230] - Thomas Goddard

Thank you, Sue. I think we've covered it. Folks, if you're watching this and you have any questions about, Well, how do I actually document this? Or, What's the process for modifying my policies and procedures to get moved from version 6.0 to 7.0? Or if you're a first time applicant for accreditation, all of this is new to you. If you have any questions of this sort or of any sort about case management or accreditation, please reach out to us with the information that we've provided along with this video. And in any event, I hope you all have an excellent day. Thank you. And thank you, Sue.

[00:35:40.290] - Sue DeMarino

Thank you, Tom.