back to basics: improving the quality of your case management services julia hidalgo, scd, msw, mph...
TRANSCRIPT
Back to Basics: Improving the Quality of Your Case Management Services
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc. & George Washington Universitywww.positiveoutcomes.net
EFFECTIVE ELIGIBILITY DETERMINATION
IN THE RYAN WHITE PROGRAM AND OTHER SYSTEMS
EFFECTIVE ELIGIBILITY DETERMINATION
IN THE RYAN WHITE PROGRAM AND OTHER SYSTEMS
Why conduct eligibility determination for HIV+ clients?
Adhere to the federal Ryan White HIV/AIDS Treatment Modernization Act of 2006
Ensure clients receive the optimal benefits that they are legally eligible
Ensure access to health care and medications through enrollment in ADAP, AICP, or other public programs
Through enrollment in commercial insurance, ensure access to a full range of health care benefits not commonly covered by the Ryan White Program
Ensure income maintenance through disability income and other income maintenance programs
Ensure that HIV clinics and other health care providers are compensated for their services
The Ryan White Program is the payer of last resort (PLR)
Grantees and subgrantees (i.e., contractors) must ensure that clients meet eligibility criteria for Ryan White-funded services Including ADAP, AICP, and direct services
Grantees and subgrantees must ensure that alternate payment sources are pursued before providing Ryan White-funded services
Grantees must establish and monitor procedures to ensure that their subgrantees verify and document client eligibility
Ryan White Program Payer of Last Resort Policies
Ryan White Program Payer of Last Resort Policies
Direct service grantees and subgrantees must document that their clients are screened for and enrolled in eligible programs and their benefits are coordinated after enrollment Medicare, Medicaid, private health insurance Other programs include public housing, drug or
mental health treatment, or Food Stamps Income assistance, including disability income and
Temporary Assistance to Needy Families (TANF) Grantees must coordinate with other funders to
ensure that Ryan White Program funds are the PLR Including coordination with the VA
These and other HAB requirements are subject to audit
Payer of Last Resort PoliciesPayer of Last Resort Policies
Components of Eligibility Determination
Applicant’s identifyHIV seropositive
status, or affected family member (for some services)
ResidencyHealth insurance
enrollmentIncome
Eligibility Determination: Pieces of the Puzzle There is a vast array of entitlement
and discretionary programs that HIV+ clients may be eligible for today and tomorrow
Eligibility criteria (the short list) Geographic residency, US
citizenship, legal residency status, age, gender, previous financial contributions by client, employment status, type of employer, preexisting medical condition, disability, employability, income, assets, HIV serostatus, CD4 count, annual or lifetime utilization of benefits, criminal convictions
Medicaid Eligibility For HIV/AIDS Beneficiaries
Assistance Category Eligibility Criteria Mandatory/Optional
Supplemental Security Income (SSI)
Severely disabled, unemployable, low-income
Mandatory
Parents, pregnant women, children
Low income, with income and asset criteria vary by assistance category and State
Mandatory, States may offer higher income threshold
Medically needy Severely disabled and low income (median=56% of FPL) after subtracting medical expenses
Optional, 35 States use this option for disabled individuals
Workers with disabilities
Severely disabled, low-income, for persons returning to the workforce
Optional
Poverty level expansion
Allows for income above SSI levels up to the FPL
Optional, 19 States use this option
State Supplemental Payment (SSP)
Allows for coverage of beneficiaries receiving SSP
Optional, 21 States use this option
Adapted from Kaiser Family Foundation HAB presentation
SSI and HIV/AIDS Substantial state variability in the acceptance rates of
SSI applications from HIV+ individuals Initial denial rates tend to be very high in most states Significant changes are being made to State Medicaid
programs due to the Deficit Reduction Act (DRA) Example: beneficiaries and applicants must document their US
citizenship Disability claims are taking longer than ever to process
Many State and federal entitlement programs have had layoffs or are working with inexperienced staff
New SSI HIV/AIDS disability criteria was published in June 2009 Adults:
http://www.ssa.gov/disability/professionals/bluebook/14.00-Immune-Adult.htm
Children: http://www.ssa.gov/disability/professionals/bluebook/114.00-Immune-Childhood.htm
SSI and HIV/AIDS In Florida, the Division of Disability Determinations
(DDD) makes decisions regarding the medical eligibility of Floridians applying for disability benefits under the federal SSDI, SSI, and the state Medically Needy program
DDD is also responsible for redeterminations Applications for disability benefits are filed at the local
Social Security Administration field office when an claimant seeks disability benefits under the Social Security Act, or at a local DCF office of the when benefits are sought for the Medically Needy program The application is forwarded to DDD for a determination of
medical eligibility The claim is then returned to either SSA or DCF for a final
determination of non-medical eligibility and effectuation of any benefits due the claimant
What has been your HIV+ clients’ experience applying and enrolling in Medicaid?
Medicare Eligibility For HIV/AIDS BeneficiariesAssistance Category Eligibility Criteria
Individuals age 65 years or older
Sufficient number of work credits to quality for Social Security payments
Individuals under 65 years of age
Sufficient number of work credits to quality for Social Security Disability Income (SSDI) payments due to disability; also includes spouses and adults disabled since childhood
Have been receiving SSDI payments for at least 24 months
Individuals with end-stage renal disease, any age
Sufficient number of work credits to qualify for Social Security payments
Adapted from Kaiser Family Foundation HAB presentation
Medicare Part D Enrollment
Implementation was challenging
HIV+ Medicare beneficiaries continue to express challenges in comparing plans
What has been your HIV+ clients’ experience with Medicare Part D?
Pop QuizWhat is the difference between SSI and
SSDI?Can you be enrolled simultaneously in
Medicaid and Medicare?True or false? A client cannot be
enrolled in Medicaid and Ryan White-funded programs?
Under what circumstances can a Medicare beneficiary receive Ryan White-funded services?
Commercial Insurance Coverage is primarily through group benefits via
employers or association membership Individual coverage can be purchased through
carriers Benefits vary substantially among carriers ED must address
Waiting periods for pre-existing medical conditions
Annual or lifetime caps Service utilization limits for specific services (e.g.,
number of prescriptions, home health visits) HIV+ beneficiaries of these plans may receive
Ryan White Program benefits during waiting periods or while services caps are exceeded
Commercial Insurance Some eligible HIV+ individuals do not seek insurance
or drop their coverage due to Concern about HIV disclosure and discrimination Growing premiums, co-payments, and deductibles
Case managers should not encourage enrollment in Ryan White Program-funded programs as a substitute to health insurance available to them However, assistance may be available through
AICP It is important to counsel clients
To retain or seek coverage during “open season” Seek improved coverage if they have limited
benefits or high premiums, co-payments, or deductibles
Pop QuizCan you be enrolled simultaneously in
commercial insurance and Ryan White-funded programs?
Can a Ryan White-funded program accept commercial insurance?
Under what circumstances can a commercial insurance beneficiary receive Ryan White-funded services?
What is HAB’s policy regarding veterans?
In 2004, HAB clarified their policy about providing Ryan White Program-funded services to HIV+ veterans who also are eligible for VA benefits: http://hab.hrsa.gov/law/0401.htm
Ryan White Program providers Should inquire if a client is a veteran and enrolled in the VA
May not deny services, including medications, to veterans who are otherwise eligible for the Ryan White Program
Should be knowledgeable about VA medical benefits, including medications
Must coordinate health care benefits for veterans
Make HIV+ veterans aware of VA services available, procedures for getting VA care, and help them to navigate HIV care
Even if enrolled in the VA, a veteran does not have to use the VA as their exclusive health care provider
What are the eligibility criteria for veterans to receive services from the VA?
Eligibility information is available at: http://www.va.gov/healtheligibility/HECHome.htm
Eligibility for most veterans health care benefits is based on active military service in the Army, Navy, Air Force, Marines, or Coast Guard, and other criteria
VA health care benefits are not just for veterans who served in combat or have a service-connected injury or medical condition
Not all veterans are eligible for VA benefitsIn recent years, VA eligibility requirements
have become increasingly strict
Eligibility for Other Publicly Funded Services
Under the Ryan White Program PLR policy, if a client is eligible for services through other publicly funded services they should be referred to those services before Ryan White Program-funded services should be provided
Examples include Substance abuse treatment services Mental health services Food/pantry services Transportation Utilities assistance
What challenges have your HIV+ clients experienced enrolling in these programs?
POP QUIZ: TRUE OR FALSE1. Physicians and other clinicians can help HIV+ patients to enroll in Medicaid2. The reception staff at HIV clinics can assist in periodic re-determination of health insurance coverage3. Re-determination should only be done once per year4. I am very familiar with eligibility requirements for Medicaid, Medicare, ADAP, and my state’s Health Insurance Continuation Program
Partners in Effective ED
Partners In Eligibility Determination
Case managers or other ED staffPhysicians documenting disabilityReception staff Other payers and other systemsLegal advocacy programs
ClientsDirect service agency
managers and HIV program directors
Effective Strategies In Working With Clients Communicate with clients that to continue to operate, your
program must have revenue Avoid the attitude “don’t ask, don’t tell,” giving the clients the
impression that there is a free lunch Providers are often unaware that clients are already enrolled or
eligible for care Concerns about discrimination and stigma are real and may result
in lack of complete disclosure Do not assume that clients can navigate the system, read,
or complete forms Conversely, do not assume that clients cannot navigate the
system when some can ED processes that rely heavily on clients are commonly
doomed Paperwork is not the highest priority when you are trying to
survive Ensure that clients receive the maximum benefit to which
they are legally entitled What other strategies do you use?
Link with HIV clinics to obtain documentation of clients’ HIV serostatus Case managers working in clinics must document
HIV serostatus in your clients’ case management charts
Use standardized forms and train personnel to use them Ensure forms are linguistically appropriate to the
subpopulations served Address the varied literacy level of clients
Clearly identify expectations to case managers regarding chart documentation
Require tax returns or credit checks to document income, assets, and employment
Role of HIV Program Directors and Case Management Supervisors
Role of HIV Program Directors and Case Management Supervisors
Role of HIV Program Directors and Case Management Supervisors
Some agencies find electronic case management software helpful in ED screening It is important that the software be updated
regularly to reflect new programs or changes in existing programs
Reflect the availability of state and local programs Review your policies and procedures with your ED
staff to determine what is actually being done Talk to your staff, assess data, and conduct your
own audits Develop continuous quality improvement (CQI) to
improve ED Train and retrain ED staff and test their knowledge
periodically Use trained and experienced supervisors
Role of HIV Program Directors and Case Management Supervisors
Systematically assess the ED processes by applying performance standards and auditing charts
Use benchmark data to compare the performance of ED staff
Do not assume that your program’s case managers are “handling it”
Many case managers report that their case loads are too high and that they are not trained to handle ED
Assess if case managers are the most cost-effective personnel model for ED
Identify entitlement and discretionary programs for which there are barriers to enrollment
Document the problem and establish ongoing processes for resolution; an important advocacy role
Communicate with other HIV programs to document system-wide barriers
How do supervisors in your agency monitor ED functions of your HIV case managers?
Routinely monitor changes in entitlement and discretionary programs that impact eligibility and adjust accordingly Changes to major payers in your community should
be rapidly communicated to ED workers Meet with county DSS staff to become familiar with
their processes, get on the list for program announcements, and ask if your staff can participate in training
Do not assume another agency will take care of ED unless that explicit role is assigned to them Coordinate with community partners if another
agency is responsible for ED Determine how client-level will be transmitted
effectively between agencies, with HIPAA requirements addressed for data transfer
Role of HIV Program Directors and Case Management Supervisors
Role of HIV Program Directors and Case Management Supervisors
Collaborate with other care systems to identify resources and coordinate referrals Other systems include substance abuse and
mental health treatment, affordable housing, pantry/nutrition programs, transportation, etc.
Legal services may be available (through Ryan White-funded programs or referral) to pursue administrative procedures following rejected disability or other claims and to assist clients in employment discrimination cases
Establish processes with SSA to fast track applications and to train disability determination staff regarding HIV disease
Are there other actions your HIV program director or supervisor can do to help you do ED?
Role of HIV Program Directors and Case Management Supervisors
Role of HIV Program Directors and Case Management Supervisors
Strategies For HIV Programs Receptionists should ask ALL clients at EACH visit for a
copy of their health insurance card, including Medicare Part D enrollment card Any changes should be reported to the case
management staff It is important that receptionists not assume that no
change has occurred At the beginning of each calendar year, it is important
to confirm insurance status Scheduling staff should confirm through the online
Medicaid system that the client is newly or still enrolled Confirm Medicaid enrollment the day before the client’s
appointment What if our agency is not a Medicaid provider?
Copies of new health insurance cards should be made and filed in the client’s chart
Effective ED Strategies
Do not front-loaded ED at entry in care Screen for eligibility on a routine basis (e.g., every
six to twelve months) Use rolling re-determination to normalize required
staffing Intake and re-determination forms should be tailored
to screen for the unique set of health and other programs in your community It is not enough to ask a client if he/she is enrolled
but assess eligibility based on the criteria used for relevant programs
Knowing how to complete the paperwork, document claims, and making sure clients follow through are the keys to success
Request the case management charts of new clients moving from other states
Medical providers must communicate with ED staff about eligibility “triggers” Loss of employment due to disability, inability to be
employed due to the side efforts of HAART, inpatient admissions, changes in clinical condition
Do not assume that clients’ disability claims should only be HIV-related, they may have other chronic conditions
Coordinate applications for benefits Avoid flooding the system with completed forms to “see
what sticks” Do not advise clients to “get a Medicaid rejection
letter” so they can access Ryan White Program-funded services Rather, work with clients to prepare valid, accurate
applications for benefits Partner with legal aid staff to prepare well documented
applications and address discrimination issues What other strategies do you use?
Effective ED Strategies
Documenting Eligibility for
the Ryan White Program and Other Funded
Services
Health and Case Management Record Basics
The chart or record is the core element of a visit or other unit of service
Since eligibility determination services are purchased by the Ryan White Program or health insurers, requirements for medical records are applicable to case management records
It is a systematically organized record of a client’s total care Everyone who records progress of care in the record should
follow the same note writing format Policies and procedures dictate its organization and use Creates a verifiable record of services provided for third party
payers and other interested parties (QI, accreditation, etc.) As such, the record should be easily navigated by an
external chart reviewer for audit or quality assessment
ED Documentation
Documentation provides the who, what, when, where, why, and how of client care
Regardless of the complexity of documentation, records must be comprehensive enough to meet regulatory, licensing, accreditation, legal, research, quality assurance, and client care needs and purposes
Record notes must be comprehensive enough to support the design and implementation of the care plan and the nature of case management services provided
ED Documentation
Information should be recorded at the time of care At least on the same day The longer the delay, the lower the quality of the entry
All staff should use the same set of approved abbreviations and symbols
All entries must be dated, timed, chronological, legible, and signed in non-erasable blue or black ink by the provider with his/her credentials noted after their name No blank spaces in between entries Do not use WhiteOut or highlighters
Corrections can only be made with a new entry, then cross out and initial old entry
If it’s not legible, it’s not there; if it’s not there, it wasn’t done
Case Conferences
Pop Quiz: Who is the Client? Case 1
Antonio is a 45 year old HIV+ construction worker that recently relocated to Orlando from New York. He and his HIV+ wife have two children ages five and two. His wife recently left him, and he is caring for the children on his own. Antonio has advanced HIV disease, and chronic orthopedic conditions that prevent him from working. He reports having no income, no health insurance, and is worried that he cannot care for his children.
Pop Quiz
Our case management program is located in a clinic, should we consider consolidating the medical and case management record? When can case managers write notes in the medical chart?
Should case managers read their client’s medical record? Should a community case manager request a copy of their client’s medical record?
Should case management record be filed centrally? Should case managers take client records with them
to visit their clients at home, in the hospital, etc.? When should automated case management records be
downloaded onto a disk or flash drive? Can a client request a copy of their case management
record?
Pop Quiz: Who is the Client? Case 1
This is what we know from intake: Antonio is a 45 year old HIV+ construction worker that recently relocated to Orlando from New York. He and his HIV+ wife have two children ages five and two. His wife recently left him to care for the children on his own. Antonio has advanced HIV disease, and chronic orthopedic conditions that prevent him from working. He reports having no income, health insurance, and is worried that he cannot care for his children.
Pop Quiz: Who is the Client? Case 2
This is what we know from intake: Marvin is a 50 year old HIV+ male that lives with his 75 year old mother. He has been HIV+ for seven years, with a declining CD4 count and increasing viral load. He is often is too depressed to go to his HIV clinic visits, take his medications, or care for himself. At intake, Marvin’s mother is unaware that he is HIV+. At the advise of his case manager, Marvin tells his mother that he is HIV+. She is depressed and anxious, as she worries that Marvin may die.
Case Conference 4
This is what we know from intake:
Marvin is a 45 year old mechanic. He was diagnosed ten years ago with HIV and has several opportunistic infections and hospital stays. He is on salvage HAART. Marvin reports that he can no longer work due to ill health. Currently, Marvin is enrolled in health insurance. He also reports that it is becoming difficult to maintain his apartment, drive to the store, and prepare his meals. His physician reports that Marvin is showing signs of HIV dementia and wasting.