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Department of Medical Assistance Services. Case Management Training. Division of Long -Term Care Department of Medical Assistance Services 2012. 1. Case Management Definition Case Management Qualifications Team approach Trends seen by analysts .

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Case Management Training

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case management training

Department of Medical Assistance Services

Case Management Training

Division of Long -Term Care

Department of Medical Assistance Services



Case Management Definition

Case Management Qualifications

Team approach

Trends seen by analysts

Face to face and Quarterlies

Interruptions and Extensions


Housekeeping Tips

goals cont
Goals cont.
  • Abuse and Neglect
  • Quality Management Reviews
  • Billing
case management cm definition
Case Management (CM)-Definition

Activities designed to assist a child or adult with DD to live in the community by . . .

accessing needed medical, psychiatric, social, educational, vocational, residential, institutional, and other supports

case manager cm qualifications
Case Manager (CM) Qualifications
  • DMAS Participation Agreement
  • Developmental Disability work experience
  • CM and SF can be the same individual
  • Undergraduate degree in a Human Services field
  • Cannot be a direct service provider
  • Back-up Coverage

12VAC 30-50-490

case manager cm qualifications1
Case Manager (CM) Qualifications
  • Employed by an organization
  • Self-employed
  • Supervisor to Case Manager
  • CM provider cannot supervise another CM provider
  • Personnel Record
  • Eight Hours of Training
case manager cm qualifications2
Case Manager (CM) Qualifications
  • Parents, Spouses or any person living with the individual
  • CM cannot provide services to own child
  • CM may provide service facilitation(SF)

12VAC 30-50-490

case management while on wait list
Case Management while on Wait list
  • Individual’swhohaveMedicaid
  • Documented in plan of care
  • Case Management Activities 12 VAC 30.50.490)
the team approach to the plan of care meeting

The Team Approach to the Plan of Care Meeting

Participant, Family, and Providers

what does the team approach ensure
Satisfaction with services

Health and safety




No breaks in service

Optimal service delivery

(DD Waiver Manual, Chapter IV)

What does the Team approach ensure?
who does the case manager contact for a plan of care meeting
Who does the case manager contact for a Plan of Care Meeting?
  • Participant and/or his/her family,
  • All current service providers and
  • Friend, Legal Guardian, significant other
  • Date/Time/Meeting location/advance notice

(DD Waiver Manual, Chapter IV)

what is the goal of the plan of care meeting
What is the goal of the Plan of Care Meeting?
  • Person Centered
  • Decision-Making
  • Discuss concerns
  • Satisfaction with Services/Meeting needs

(DD Waiver Manual, Chapter IV)

what is the goal of the plan of care meeting1
What is the goal of the Plan of Care Meeting?
  • Short and Long-term goals
  • Focus of meeting
  • Target date
  • Effective and Consistent

(DD Waiver Manual, Chapter IV)

case management
Case Management
  • What is Case Management?
    • Case Management activities include:
      • Assessing and planning
      • Linking
      • Coordinating
      • Monitoring/Follow up
      • Making Collateral Contacts
      • Advocating
      • Education and Counseling
      • Enhancing community integration (12 VAC 30.50.490)
what are other important topics
What are other important topics?
  • Freedom of Choice
  • Future planning:
    • Aging
    • Graduation/Transition Planning
    • Aging Caregiver
    • Behavioral/Crisis Planning
  • Contingency plans
choice of services
Choice of Services

Why is choice important?

  • Empowering
  • In control of their lives
  • Helps CM to develop the POC

Who makes the choice?

  • Is the participant over 18?
  • Does he/she have the ability to make their own choices?
  • Does he/she direct his own care?
  • Does he/she have a legal guardian?
resources to help with choices
Resources to help with Choices

Network with other Case Managers

DMAS website

Develop your own provider list for your families


Trends Seen By DD Waiver Analyst

trends seen by analysts
Trends Seen By Analysts
  • Level of Functioning Assessments
  • DMAS 456
  • Social Assessment
  • DMAS 457
  • DMAS 97 A/B
  • DMAS 99
  • Environmental Modifications
trends seen by analysts1
Trends Seen by Analysts
  • Assistive Technology
  • Consumer Directed and Agency Directed Companion
  • In-Home Residential
  • Therapeutic Consultation
  • Denial of Services
how to reduce trends
How to reduce Trends
  • The key to successful plan submissions is error free work
  • Double check that no spaces are left blank and that the documentation matches the requested hours of service
  • Complete justification is required for requests for services including adding new services, increases or decreases in services and/or service hours
how to reduce trends1
How to reduce Trends

Use the DD Waiver Fax Sheet

  • Please use the fax cover sheet
    • Identify the type of plan and include any special instructions you may have for DMAS
  • Resubmissions/Pend responses
    • Identify on the new fax sheet what your resubmission is addressing
    • Note when submitting a response to a pend you do not need to resubmit the entire packet. You only need to submit the information that is being requested on the Case Manager Status Report
face to face meetings
Face to Face Meetings
  • A face to face (FF) visit is defined as …

the case manager or service provider must meet with the individual in person and that the individual should be engaged in the visit to the maximum extent possible. (12VAC30-120-700)

    • A face to face contact is required at a minimum of every 90 days. (Chapter IV, 12 VAC 30-50-490)
face to face meetings1
Face to Face Meetings
  • Documentation Requirements:
    • FF with individual
    • Assessment of service satisfaction
    • Any unmet needs
    • Individual’s status
    • Service modification

(DD Waiver Manual, Chapter IV)

tips for ff
  • Case notes may be in the form of contact-by-contact entries or a monthly summary as long as they correspond with a contact log. These notes must include the date, type, and reason for each contact.
    • All entries must be signed (first initial and last name minimum) and dated.
    • Face to face visit notes are not quarterly reports and need to be documented separately.
case management review
Case Management Review

At a minimum, every three months review:

  • Plan of care equals a FF with the individual
  • Quarterly goals and objectives to ensure they are being met, and
  • Any necessary modifications to the plan of care
case management review1
Case Management Review
  • At least once per plan of care year this review must occur in the individual’s home environment.


why is this process separate from the face to face contact meetings
Why is this process separate from the face to face contact meetings?
  • Comprehensive evaluation must include the following:
      • The DMAS 457 support documentation which includes all of the individuals goals and objectives as agreed upon in the team meeting.
      • The plan of care which includes all DD waiver services including case management.
      • The service providers quarterly reports submitted to the case manager. (12VAC30.120.720.E.1.b)
these are the required components for your quarterly report
These are the required components for your Quarterly Report
  • Revisions to the Plan Of Care
  • General status
  • Significant events
  • Progress or lack of progress in goals
  • Satisfaction with Services and Case Management (DD Waiver Manual, Chapter IV)
quarterly review
Quarterly Review
  • All service providers must complete a written semiannual report and forward to the case manager.
quarterly review1
Quarterly Review
  • Exception! When any sporadic and temporary services such as Respite, Assistive Technology, Environmental Modification, PERS and Crisis Stabilization are provided during the quarter, the case manager must obtain details of the services from those providers and include this information in the Quarterly report. (DD Waiver manual, Chapter IV)
goal and objective review
Goal and Objective Review
  • The Quarterly Review schedule is based on the start date of the POC.
  • Initial plan year view

POC Start Date Quarterly Due Semi Annual Due Quarterly Due Jan 1, 201 April 1, 2012 July 1, 2012 October 1, 2012

Months 1 2 3 4 5 6 7 8 9 10 11 12

goal and objective review1
Goal and Objective Review
  • Quarterly Reviews are planned around the POC start date.
  • Renewal Plan Year View

Annual Plan Due Quarterly Review Semiannual Due Quarterly Due

January 1, 2012 April 1, 2012 July 1, 2012 October 1,2012

Months 13 14 15 16 17 18 19 20 21 22 23 24

processing plans of care poc
Processing Plans of Care (POC)
  • Emergency plans

What is considered an emergency?

      • It is at the discretion of DMAS staff whether a plan falls into the emergency criteria for a plan to be worked out of the normal work flow
      • When a Case Manager requests emergency consideration, a team review will take place prior to the deciding to work the plan
emergency poc
Emergency (POC)
  • Most emergency plans are medical in nature
  • Poor planning on your part does not constitute an emergency
emergency poc1
Emergency (POC)
  • Examples of emergency plans:
    • A participant has broken her hip and needs additional hours of service
    • A participant is experiencing skin breakdown and needs additional hours
    • How do you define an emergency?
processing emergency poc
Processing Emergency (POC)

Crisis vs. Emergency

  • Crisis is defined as a mental health emergency
  • DMAS is required to review crisis plans as they are received so authorization can be obtained within 72 hours
the difference between extension letters and interruptions
The difference between Extension Letters and Interruptions
  • Extensions are requested prior to beginning services
  • Interruptions are requested after the participant has started service and has not received services in thirty days
when is an extension letter needed
When is an Extension letter needed?
  • When a participant is unable to initiate services within 60 calendar days of becoming Medicaid eligible and enrolled an extension letter is required (DD Waiver Manual, Chapter IV)
what are the extension letter requirements
What are the extension letter requirements?
  • Requests must be in writing
  • Letters must be received by DMAS within the 30 day period the extension is requested
  • No more than 4 extensions may be approved
  • Extension letters must contain the specific start and end dates for the requested time period
  • Extension letters must contain information why more time is needed to initiate waiver services


when are plan interruptions needed
When are plan interruptions needed?
  • When a participant has not received DD Waiver services for more than 30 days
  • It is the Case Manager’s responsibility to submit an Interruption POC to DMAS
how do you interrupt a poc
How do you interrupt a POC?
  • If possible, the Case Manager should meet with the participant and/or family member to obtain their signature on the Plan of Care
  • (Note: participants should be notified that services can only be interrupted for 90 days and then the withdrawal process will begin)
how do you interrupt a poc1
How do you interrupt a POC?
  • At the top of the Plan of Care, the Case Manager should check the box for “Interruption” and update the DMAS 457 to explain why services are being interrupted then submit the documents to DMAS
how do you restart a poc
How do you restart a POC?
  • Meet with the participant and/or family and providers to discuss the POC
  • Resubmit the updated POC marked “Revision” with an updated 457
  • The supporting documentation for the services being requested
    • Note: DMAS has the same work time for restarting a POC as regular plans that are submitted daily. (DD waiver manual, Chapter 4)
transfer of case management
Transfer of Case Management
  • If a participant wishes to “switch” to another case manager, the current CM is responsible for:
    • Send a Case Management list
    • Informing the participant that the Case Manager needs written permission to exchange information (a copy of your agency’s Consent Form) with the new case manager they have selected
transfer of case manager
Transfer of Case Manager
  • When a participant has selected another case manager and provided consent to exchange information,
  • The existing case manager copies the complete record and forwards it to new case manager
transfer of case manager1
Transfer of Case Manager
  • Current case manager needs to follow-up with a phone call and document that they updated the new case manager on the case
  • The case manager must inform DMAS and individual in writing of the change (fax is fine) and submit a copy of the consent form to DMAS
housekeeping tips1
Housekeeping Tips
  • Verify that all paperwork submitted by providers is correct prior to submitting it to DMAS
  • Ensure that plans and supporting documentation are submitted to DMAS in a timely manner
  • Submit renewal plans no earlier than 60 days prior to plan start date
  • Required Documentation
    • POC can only be worked with submission of complete documentation. Please refer to your Provider Manual for required documentation, service limits, and exclusions.
  • Participants should be notified that services can only be interrupted for 90 days and then the withdrawal process will begin.
  • DMAS has the same work time for restarting a POC as regular plans that are submitted daily.
housekeeping tips2
Housekeeping Tips
  • Case Management and Service Facilitation documentation should be separate
  • Legible writing
  • Objective written documentation notes as to why there are no other providers available to provide care this includes advertisements and number of attempts.
  • Document, Document, Document
we need your help
Children's Stats

In FY 2011 CPS received

49,619 reported cases of abuse or neglect

6,116 were founded cases

30% under the age of 4

Virginia APS

received over 17, 936 reports of adult abuse, neglect and/or exploitation.

59% of the reports were substantiated

We Need Your Help!
for this purpose
Adults are:

Persons 18 years old or older who are incapacitated

Persons age 60 and older

Children Are:

- Persons under the age of 18 years

For this purpose . . .
types of abuse






Self Neglect






Home Alone



Types of Abuse

Financial Exploitation is a growing trend in Abuse

what is a mandated reporter
What is a Mandated Reporter?
  • A mandated reporter is an individual who is required by Virginia law to report situations immediately in which

they suspect anyone that

may have been abused,

neglected or exploited,

or is at risk of being abused,

neglected or exploited

who must report
Who must report?
  • Medical professionals § 54.1-2503 of the Code of Virginia,
    • Persons licensed to practice medicine or any healing arts
    • Hospital residents, interns, and nurses
    • Any emergency medical services personnel certified by the Board of Health § 32.1-111.5
  • Social workers and Probation officers
    • 54.1-2400.1
  • Teachers and school personnel
    • Public, private, kindergarten or nursery school
  • Child care providers
who must report1
Who must report?
  • Accredited Christian Science practitioners
  • Mental health professionals
  • Law enforcement officers
  • Professional staff
  • Mediators certified to receive court referrals
  • Designated court appointed special advocates
employers of mandated reporters
Must notify mandated reporters of their obligation to report

May establish in-house procedures for reporting

Cannot prohibit employees from reporting directly to APS

Employers of Mandated Reporters:
when do i report
WHEN do I report?
  • Report situations they encounter while performing their official job duties
  • The report must be made immediately upon becoming aware of the situation of abuse, neglect and/or exploitation
making a report
Making a Report
  • When to report
    • Immediately
  • How to report
    • Call local department of social services
    • Or call Hotline 24 hrs a day, 7 days a week
  • WHAT do I report?
    • The identity, age, and location of the alleged abused individual
    • Any information about the suspected abuse, neglect or exploitation

For Children


For Adults

1 (888) 832-3858)

questions for aps dss specialists
Questions for APS DSS Specialists

If you have questions about reporting suspected adult abuse, neglect and/or exploitation, or other questions regarding your status as a mandated reporter, call an APS DSS Regional Specialist:

Eastern Region (757) 491-3983

Central Region (804) 662-9783

Western Region (276) 676-5636

Piedmont Region (540) 204-9640

Northern Region (540) 347-6313

you are key
You are Key!

Report suspected Abuse, Neglect and Exploitation!

You can help vulnerable children and adults suffering in silence have safer, happier and more productive lives!

questions and answers
Questions and Answers

For questions, please contact the Division of Long-Term Care at 804-225-4222, press option #1 or by fax at 804-612-0050.

Please visit the DMAS website at:

Thank You!!!!!!

look ahead
Look Ahead
what to expect during a quality management review qmr

What to Expect During a Quality Management Review(QMR)

Department of Medical Assistance Services

what generates a review
What Generates a Review?
  • Statewide Sample
    • A computer generated list is created and reviews are scheduled randomly.
  • Complaints
    • DMAS receives a concern regarding services from a constituent.
quality management review


  • May be on-site or desk review
  • May include
    • observation of service delivery,
    • face to face or telephone interviews with the consumer and caregivers.
  • Usually 2 – 5 days in length

Quality Management Review

qmr cont d
QMR (cont’d)

Upon arrival, Analyst will:

  • Request charts be gathered together in a central location.
  • Secure a workplace to conduct the review.
qmr con t
QMR (con’t)
  • Electronic Records
    • Analyst should have access to electronic records
    • Analyst may request that some portions be printed
    • No personal information from the analyst will be supplied in order to gain access to the electronic record.
qmr cont d1
QMR (cont’d)

During the review:

  • Analyst may ask questions regarding your documentation.
  • Analyst may request additional documentation.
  • Analyst will let you know how long the review will last and time of the Exit Conference.


quality management review cont d
Quality Management Review (cont’d)
  • Exit Conference will usually occur on the last day of the review and may be via telephone or alternate media.
  • You may have any of your staff attend.
items to be reviewed
Items to be Reviewed
  • Assessments
  • Plan Of Care (CSP)
  • Supporting Documentation (457)
  • Quarterly/Semiannual Reports (of other providers)
  • CM documents and documentation
items to be reviewed cont
Items to be Reviewed (cont.)
  • Individual records
    • Appropriate data, contact notes, or progress notes
    • Reports
    • Documentation
items to be reviewed cont1
Items to be Reviewed (cont.)
  • Personnel records (qualifications, background check, references)
  • Policies and Procedures (At a Minimum)
    • Hiring
    • Development of Service Plans
    • Admissions and Intake
    • Reporting of APS and CPS cases
    • Record Retention
qmr findings letter contents
QMR Findings Letter Contents
  • Summary
  • Technical Assistance
    • Issues not in compliance with Medicaid policy that should be addressed by the provider.
  • Corrective Action Plan (CAP)
    • Situations in which the provider has failed to comply with federal and state regulations or policy guidelines and procedural changes are required.
recent findings trends
Recent Findings Trends
  • Documentation demonstrates consumers are receiving any necessary medical care.
  • Documentation of side effects of medication and all health, safety and welfare incidents or concerns.
recent findings trends cont d
Recent Findings Trends (cont’d)
  • Documentation of progress towards CSP goals and or changes.
  • Annual documentation includes summary of each quarter, satisfaction with each service and justification for continuation or discontinuance of services/waiver.
recent findings trends cont d1
Recent Findings Trends cont’d
  • Quarterly review of status of each service participant is receiving or service authorized on CSP.
  • Quarterly review accurately reflects the individual’s responses to services for the quarter.
  • Quarterly review documents participants choices and involvement with development of plan.
recent findings trends cont d2
Recent Findings Trends (cont’d)
  • The Case Manager’s quarterly review includes a summary of each providers quarterly or semi-annual review.
  • The Case Manager’s quarterly review is completed within the required timeframe.
  • CM job responsibilities are completed regardless of billing status.
recent findings trends cont d3
Recent Findings Trends (cont’d)
  • Face–to–Face contact occurs at least every 90 days.
  • Documentation of Face–to-Face contact include components required per manual and VAC regulations.
  • All CM and SF documentation maintained separately.
recent findings trends cont d4
Recent Findings Trends (cont’d)
  • Billable and legible monthly CM contact notes.
  • Contact notes signed and dated.
  • Participant’s full name or Medicaid number on each page.
  • Health and safety needs documented in plan and reflected in services.