CASE MANAGEMENT COMMITTEE MEETING€¦ · V. OBSERVATION NOTIFICATION Staff Rogers provided an...

CASE MANAGEMENT

COMMITTEE MEETING

Wednesday, January 25, 2017 10:00 am – 2:00 pm

CALIFORNIA HOSPITAL ASSOCIATION BOARD ROOM

1215 K Street, Suite 800 Sacramento, CA 95814

rlauborough

Typewritten Text

CASE MANAGEMENT COMMITTEE

MEETING AGENDA

Wednesday, January 25, 2017

CALIFORNIA HOSPITAL ASSOCIATION

1215 K Street, Suite 800 – Board Room

Sacramento, CA

Call-in: (800) 882-3610; Passcode: 4920025#

Adobe Connect: https://connectpro16666225.adobeconnect.com/_a932421402/cmc01252017/

ITEM SUBJECT REPORTING TIME PAGE *Action Item

I. CALL TO ORDER/INTRODUCTIONS Brown 10:00

II. MINUTES OF PREVIOUS MEETING Brown 10:05

September 28, 2016 Meeting Minutes

November 16, 2016 Call Summary

Recommendation: approve meeting minutes

5 9

III. CHAIR REPORT

A. Membership Update

Case Management Committee Roster

Brown

10:10

11

IV. LEGISLATIVE UPDATE

A. Federal Legislative Update

ACA Talking Points

MediCal Coverage Chart

B. State Legislative Update

O’Rourke

Glaser/Hawthorne

10:15

10:30

15

17

19

21

V. WORKFORCE

CSU Curriculum Guidelines

Foundational Case Management

Curriculum

Foundational Utilization Review

Curriculum

Blaisdell/All 10:45

23

25

37

https://connectpro16666225.adobeconnect.com/_a932421402/cmc01252017/

CHA Case Management Committee Meeting Agenda Page 2

January 25, 2017

Advance Concepts Care Management

Curriculum

Leadership Curriculum

45

53

VI. OBSERVATION NOTIFICATION

MOON Form

MOON Form Instructions

Health and Safety Code 1253.7

Rogers/All 11:00 61

65

67

69

LUNCH 12:00

VII. DISCHARGE DELAY STUDY Rogers 12:30 71

VIII. DISCHARGE TO RCFE Rogers 12:45 73

IX. CURRENT ISSUES

A. End of Life Option Act

B. Unrepresented Patient

C. CCI, Cal MediConnect

D. PACE Partnership

Blaisdell/Rogers 12:50 79

X. ROUNDTABLE All 1:30

XI. ADJOURNMENT

Next Meeting:

Wednesday, March 22, 2017

10:00 AM – 2:00 PM

CHA- Board Room

1215 K Street, Suite 800

Sacramento, CA

2017 Meeting Dates

2:00

81

CHA CASE MANAGEMENT COMMITTEE MEETING

California Hospital Association

Sacramento, CA

Wednesday, September 28, 2016

10:00 am – 2:00 pm

Present: Marcy Adelman, Michael-Anne Browne, Diane Brown, Theresa

Kurtinaitis, Elizabeth Polek, Martha Mleynek, Lisa Stroud, Shelley

Stelzner

By Phone: Mary Cummings, Heather Esget, Cindy Laughton, Michelle Evans

Staff: Cathy Martin, Lois Richardson, Debby Rogers, Susan Lowe, Patricia

Ward, Pat Blaisdell, Rosie Lauborough

RVPs: Julia Slininger, Judith Yates

I. CALL TO ORDER

Char Brown called the meeting to order at 10:13 am.

II. MINUTES OF PREVIOUS MEETING

The minutes of the June 22, 2016 meeting were reviewed and were approved.

III. CHAIR REPORT


Chair Brown provided an update on membership and welcomed Shelly Stelzner of

NorthBay Healthcare to the committee.

5

CHA Case Management Committee

September 28, 2016 Meeting Minutes 2

IV. WORKFORCE

Staff Blaisdell and Martin provided an update on communications with representatives of

California University (CSU) regarding the development of customized training to meet the

needs of California hospitals and health systems.

Kurtainitis provided an update on the meeting of the task force on curriculum development

with representatives of CSU San Marcus.

Preliminary curriculum outlines will be shared with committee members for further

discussion.

V. OBSERVATION NOTIFICATION

Staff Rogers provided an update on the federal NOTICE Act as and the Medicare Outpatient

Observation Notice (MOON) form as well as an update on the current state legislation, SB

1076. Requirements for observation services were discussed in detail.

Staff Rogers will send out the SB1076 Bill to all committee members.

CHA will consider conducting a webinar on State & Federal requirements after the

MOON form is finalized by CMS.

VI. DURABLE MEDICAL EQUIPMENT

Staff Blaisdell provided an update on the CHA advocacy regarding the Medicare competitive

bidding program for durable medical equipment and discussed with members, their

experiences of case managers in obtaining DME for their patients.

Blaisdell will distribute webinar materials to the committee. This discussion will be

added to the next committee meeting for further discussion.

VII. UNREPRESENTED PATIENT

Staff Richardson provided an update on the current status of state action in response to the

court decision, CANHR v. Chapman and discussed with members the next steps for CHA.

The CHA Case Management Committee will continue to monitor this issue in 2017.

VIII. CAL-MEDI CONNECT/COORDINATED CARE INITIATIVE

Staff Blaisdell gave an update on the status of CMC/CCI training developed for case

managers and requested input from the committee members on their experience in working

with Managed Medi-Cal Plans, including CMC plans. The recently released dual plan letter

(DPL) was also reviewed and discussed by the committee.

CHA Case Management Committee

September 28, 2016 Meeting Minutes 3

IX. DISCHARGE DELAY

Staff Rogers and Susan Lowe, Intern, discussed the outcome of the discharge delay study.

Preliminary results indicate that delays are most frequently seen for Medi-Cal beneficiaries

and for persons with mental health or behavioral issues.

Survey results will be sent to the committee for review and comment at the next

committee meeting.

X. CURRENT ISSUES

Staff Blaisdell and Rogers discussed the current issues of discharge to RCFEs. Staff Blaisdell

provided an update on state legislation bills and other State Legislation bills of interest to

hospitals and post-acute care providers as well as results of the recently completed legislative

session.

XI. ROUNDTABLE

All members discussed how working and partnering with county programs for behavioral

issues could help many of the topics discussed.

XII. NEXT MEETING

WEDNESDAY, NOVEMBER 16, 2016

10:00AM – 11:00AM

Conference Call: 800-882-3610

Pass Code: 4920025#

XIII. ADJOURN

Chair Brown adjourned the meeting at 2:00 pm.

7

CHA CASE MANAGEMENT COMMITTEE

CONFERENCE CALL

MEETING SUMMARY


Sacramento, CA

Wednesday, November 16, 2016

10:00 am – 11:00 am

I. CALL TO ORDER

Staff Blaisdell called the meeting to order at 10:15 a.m.

II. MINUTES OF PREVIOUS MEETING

The minutes of the September 28, 2016 meeting were reviewed and were approved.

III. CHAIR REPORT


IV. COMMITTEE ACTIVITES / UPDATES

A. Workforce/ CSU Curriculum Development

Staff Blaisdell will distribute information on curriculum for comment.

B. Observation Notification – MOON Form and SB1076

C. Durable Medical Equipment

D. Cal-MediConnect/CCI

E. Discharge Delay

V. ADJOURNMENT

Staff Blaisdell adjourned the meeting at 11:00 a.m.

9

CASE MANAGEMENT COMMITTEE

2017 Membership Roster

CHAIR CHAIR-ELECT

Diane Brown, PhD, RN, CPHQ, FNAHQ, FAAN

Executive Director, Care Coordination

Kaiser Permanente, Northern California

1950 Franklin Street, 19th Floor

Oakland, CA 94612

O: 510-987-3769

[email protected]

Elizabeth Miller, RN, MSN

Executive Director, Care Management

Adventist Health

1025 Creekside Ridge Drive, Suite 100

Roseville, CA 95678

O: 916-783-2542

[email protected]

MEMBERS

Marcy Adelman, RN, CCM, MSN

Clinical Resource Management

Palomar Health

456 E. Grand Ave.

Escondido, CA 92025

O: 442-281-5551

[email protected]

Regina Berman, RN, MA,

Vice President, Population Health Management

Memorial Care Health System

17360 Brookhurst Street

Fountain Valley, CA 92708

O: 714-377-3016

[email protected]

Laura Biscaro, RN

Director of Care Management

Santa Barbara Cottage Hospital

PO Box 689

Santa Barbara, CA 93102

O: 805-367-2115

[email protected]

Michael-Anne Browne, MD

Associate CMO for Accountable Care

Stanford Children’s Health

725 Welch Road

Palo Alto, CA 94304

O: 310-704-2601

[email protected]

Mary Cummings, RN, MSN, ACM

Manager, Case Management/Denial Recovery

Unit

Fresno Heart and Surgical Hospital

15 E Audubon Dr.

Fresno, CA 93720

O: 559-433-8030

[email protected]

Karen Dunning

Vice President, Care Management Operations

Sutter Health System Offices

2890 Gateway Oaks Drive, Suite250

Sacramento, CA 95833

O: 916-649-4077

[email protected]

11

mailto:[email protected]








Case Management Committee

2017 Membership Roster Page 2

Heather Esget, RN, BSN, ACM

Director of Case Management

Shasta Regional

1100 Butte St.

Redding, CA 96001

O: 530-229-2841

[email protected]

Michelle Evans

Case Management Manager

Enloe Medical Center-Esplanade Campus

1531 Esplanade

Chico, CA 95929

O: 530-332-7043

[email protected]

Cindy Laughton, RN, MA

Regional Director, Care Coordination

UHS

36485 Inland Valley Dr.

Wildomar, CA 92595

O: 951-200-8885

[email protected]

Martha Mleynek, RN, BSN, MBA

Executive Director, Case Management Services

Riverside Community Hospital

4445 Magnolia Avenue

Riverside, CA 92501

O: 951-788-8324

[email protected]

Elizabeth Polek, MBA, LCSW

Director of Patient Transition Management

UCSF Medical Center

505 Parnassus Avenue

San Francisco, CA 94143

O: 415-353-2650

[email protected]

Sally Ramirez, RN, MLTCA

Regional Director, Care Management

Standards & Practice

Providence Hospital

501 S. Buena Vista Street

Burbank, CA 91505

O: 818-847-3316

C: 626-733-7449

[email protected]

Terri Scott, RN, BSN

Regional Senior Director, Care Coordination

Dignity Health/Greater Sacramento Service Area

10901 Gold Center Drive

Rancho Cordova, CA 95670

O: 916-631-3066

[email protected]

Tonya Soroosh, RN, BS, CCM, CCP

Director, Case Management/Social Work

Sharp Memorial Hospital/Sharp Mary Birch

3003 Health Center Dr, San Diego, CA 92123

O: (858) 939-4003

[email protected]

Shelley Stelzner, RN, BSN, MHA, CCM, CPHM

Director, Case Management

NorthBay Healthcare

1200 B. Gale Wilson Blvd.

Fairfield, CA 94533

O: 707-646-4241

[email protected]

Tessie Sulit Wagoner, RN-BC, MHA, BSN,

CCM, IQCI

Regional Senior Director, Case Management

Kindred Healthcare/West Region

200 Hospital Circle

Westminster, CA 92783

O: 714-899-5020

[email protected]










Case Management Committee

2017 Membership Roster Page 3

REGIONAL ASSOCIATION REPRESENTATIVES

Ivonne Der Torosian, MPA, BSM

Regional Vice President

Hospital Council

1625 E. Shaw, Suite 139

Fresno, CA 93710

O: 559-650-5694

[email protected]

Jenna Fischer

Vice President, Quality and Patient Safety

Hospital Council

3480 Buskirk Ave., Ste 205

Pleasant Hill, CA 94523

O: 925-746-5106

[email protected]

Julia Slininger, RN, BS, CPHQ

Vice President, Quality and Patient Safety

Hospital Association of Southern California

515 Figueroa Street, Suite 1300

Los Angeles, CA 90071

O: 213-538-0766

[email protected]

Judith Yates

Senior Vice President

Hospital Association of San Diego & Imperial

Counties

5575 Ruffin Road, Suite 225

San Diego, CA 92123

O: 858-614-1559

[email protected]

STAFF

Patricia L. Blaisdell, FACHE

Vice President, Continuum of Care




O: 916-552-7553

[email protected]

Boris Kalanj

Director, Cultural Care & Patient Experience

Hospital Quality Institute



O: 916-552-7694

[email protected]

Rosie Lauborough

Administrative Assistant




O: 916-552-7546

[email protected]

Debby Rogers, RN, MS, FAEN

Vice President, Clinical Performance and

Transformation




O: 916-552-7575

[email protected]

13









January 25, 2017

TO: Case Management Committee Members.

FROM: Anne O’Rourke, SVP, Federal Legislative Affairs.

SUBJECT: Federal Legislative Update

SUMMARY

The 115th

Congress convened on Jan. 3 in Washington, DC. One of the first items on the agenda

for the Republican majority is to move quickly to repeal the Affordable Care Act (ACA).

ACTION REQUESTED

To provide an update regarding the current status of legislative efforts to repeal and

replace the Affordable Care Act.

To provide information to assist members in understanding the new political landscape,

alternative plans that might be considered, as well as the procedural steps and tactics

required to repeal, replace and/or delay ACA.

DISCUSSION

CHA maintains a full-time presence in Washington, D.C., to effectively advocate on legislative

and regulatory policy, and collaborates on policies and strategies for health care issues with the

American Hospital Association and other national health care organizations. On behalf of

members, CHA provides input on developing federal legislation and regulatory proposals, and

helps shape national positions on important health care issues.

15

Revisiting the Affordable Care Act

Talking Points

January 4, 2017

California hospitals have long supported affordable health coverage for all Californians. CHA’s priority

is preserving coverage for the 3.7 million Californians and 21 million Americans who gained coverage

under the Affordable Care Act (ACA) through the Medicaid expansion, and millions more who purchased

insurance because of the premium subsidy.

CHA supports keeping existing coverage for millions of Californians until a viable replacement is passed

by Congress and signed into law.

Key delivery system reforms, adequate payment rates and quality improvement efforts must be

maintained.

If policymakers choose to repeal the ACA without offering a replacement bill, it is essential that they

either put the savings from repeal into a reserve fund to be used for future replacement efforts, or

eliminate the payment reductions for hospital services that were part of the ACA.

A new study from Dobson|DaVanzo found that, if the ACA is repealed without an accompanying

bill providing simultaneous coverage, the net impact to hospitals nationwide from 2018 to 2026

would be $165.8 billion from the loss of coverage.

Hospitals also sustained reductions — as did other stakeholders — under the ACA that were

redeployed to help fund coverage for millions of Americans. The Dobson|DaVanzo study found

that, if the ACA is repealed and Medicare inflation update reductions for inpatient and outpatient

hospital services are not restored, funding would be reduced by $289.5 billion between 2018 and

2026 nationwide (more than $50 billion in cuts to California hospitals)

On top of that, failing to fully restore both Medicare and Medicaid disproportionate share hospital

(DSH) payments would add another $102.9 billion in cuts to hospitals.

The combined losses from the Medicare and Medicaid cuts cited above, $50 billion in California,

would be devastating. Many hospitals’ viability would be threatened, and millions of Californians

would lose access to care.

The Medicare Payment Advisory Commission estimated in March 2016 that hospital Medicare

margins would drop to an all-time low of negative 9 percent in 2016. Cuts described above could

push the losses to an estimated negative 15 percent margin by 2026.

For many hospitals and health systems, these cuts are not sustainable.

17

Infants

1-18

19-44

45-54

55-64

65-74

75-84

85 - Over

Californians

of all ages

benefit from

the Medi-Cal

expansion

• 1 in 3 California residents rely on Medi-Cal for coverage

• 3.7 million children, family members and seniors gained

coverage through the Medi-Cal expansion

• The Medi-Cal expansion provides coverage for more than an

estimated 1 million children, nearly a half million seniors, and

more than 1 million low-income working individuals

• The Medi-Cal expansion covers a diverse population,

including nearly 2.4 million Latinos, African Americans and

Asian Californians

California Counties

Estimated

Enrollment

Allowed Under

the ACA

Expansion

Alameda 94,033

Alpine 97

Amador 2,319

Butte 23,797

Calaveras 3,428

Colusa 2,477

Contra Costa 74,448

Del Norte 4,146

El Dorado 10,485

Fresno 141,916

Glenn 3,404

Humboldt 18,479

Imperial 26,477

Inyo 1,468

Kern 108,463

Kings 16,200

Lake 10,760

Lassen 2,688

Los Angeles 1,050,790

Madera 19,404

Marin 13,280

Mariposa 1,362

Mendocino 13,788

Merced 45,463

Modoc 1,082

Mono 930

Monterey 54,584

Napa 10,438

Nevada 7,307

Orange 280,643

Placer 17,067

Plumas 1,631

Riverside 229,771

Sacramento 157,036

San Benito 2,697

San Bernardino 234,212

San Diego 242,852

San Francisco 55,821

San Joaquin 50,573

San Luis Obispo 20,046

San Mateo 41,520

Santa Barbara 42,564

Santa Clara 119,784

Santa Cruz 25,507

Shasta 22,686

Sierra 204

Siskiyou 6,191

Solano 41,730

Sonoma 40,830

Stanislaus 104,225

Sutter 11,477

Tehama 7,351

Trinity 1,673

Tulare 71,677

Tuolumne 4,136

Ventura 74,805

Yolo 18,886

Yuba 8,889

Total 3,700,000

Californians Gained Stability and Access to

Health Care From the Medicaid Expansion

December 8, 2016 coverage estimates include estimated allocations and distribution information from DHCS

enrollment by county, age and ethnicity found on the DHCS website at www.dhcs.ca.gov.

19

http://www.dhcs.ca.gov/

January 25, 2017

TO: Case Management Committee Members

FROM: Barbara Glaser, Sr. Legislative Advocate

Alex Hawthorne, Legislative Advocate

SUBJECT: State Legislative Update

SUMMARY

The California Legislature returned on Jan. 4 to Sacramento for the 2017-18 legislative session.

Additionally, Governor Brown released his 2017-18 budget proposal on January 10.

ACTION REQUESTED

To provide an update on CA state budget and impact on hospitals, including implications

for the Cal MediConnect and the Coordinated Care Initiative (CCI).

To discuss the upcoming legislative session and anticipated legislation of interest to

hospitals and case managers.

DISCUSSION

Budget (CMC)

The Governor has released his state budget plan of $177 billion for the 2017-18 fiscal year. In

presenting the plan, the Governor stressed the need to practice fiscal prudence, as California’s

growth has slowed down with revenues coming in below projections by $1.3 billion.

The budget continues implementation of federal health care reform, which includes the

expansion of Medi-Cal to cover childless adults with incomes up to 138 percent of the federal

poverty level. Caseload in Medi-Cal has increased from 7.9 million in 2012-13 to a projected

14.3 million in 2017-18, covering over one-third of the state’s population. Beginning this year,

the state assumes a 5 percent share of cost for the optional expansion population. For now, this

budget continues to reflect existing state and federal law.

In regards to the Coordinated Care Initiative (CCI), the budget concludes that CCI does not meet

statutory savings requirements and therefore discontinues several specific provisions of CCI that

address IHHS. The components proposed to be discontinued are: (1) remove IHSS benefits from

plan capitation rates, (2) eliminate statewide authority responsible for bargaining IHSS workers’

wages and benefits in the seven CCI counties; and (3) re-establish the state-county share of cost

arrangement for the IHSS program that existed prior to the implementation of CCI. The net result

21

State Legislative Update

January 25, 2017

Page 2

of these three changes is a General Fund savings of $626.6 million in 2017-18. However, the

budget proposes to extend the Cal MediConnect program, continue mandatory enrollment of

dual eligibles, and the integration of long-term services and supports, except IHSS, into managed

care. It also encourages plans and counties to continue collaboration on care coordination.

The release of the Governor’s budget begins the formal budget process. Over the next several

months budget subcommittees will hold hearings on the various aspects of the budget. In mid-

May the Governor will release a revised budget plan that reflects the most up-to-date revenue

and expenditure information as well as any changes affecting health care coming out of

Washington, D.C.

Legislation

CHA monitors proposed legislation and will identify and track bills of particular interest to CHA

member hospitals. At this early stage of the legislative session, bill proposals are in the process

of being introduced.

Unrepresented Patient

A 2015 court decision, California Advocates for Nursing Home Reform (CANHR) v. Chapman

(Director of the Department of Public Health), declared unconstitutional a California statute that

permits skilled nursing facilities (SNFs) to use an interdisciplinary team to make medical

decisions for a patient who lacks capacity and has no family or other representative to make

these decisions. During the 2016 recent legislative session, the California Department of Public

Health (CDPH) proposed legislation on this issue, but withdrew the bill from consideration when

they were unable to adequately address stakeholder concerns.

CHA is working in coordination with the California Association of Health Facilities (CAHF) and

the California Medical Association (CMA) to develop legislative language to be introduced

during the current legislative session.

January 25, 2016


FROM: Pat Blaisdell, VP Continuum of Care

Debby Rogers, VP Clinical Performance and Transformation

SUBJECT: Workforce Planning

SUMMARY

CHA member hospitals report significant challenges in recruiting case management personnel.

Workforce development was identified as a priority issue for committee work for 2016.

ACTION REQUESTED

To solicit input regarding curriculum outlines developed by staff at California State

University (CSU) and to identify next steps for action.

DISCUSSION

Committee members have expressed interest in supporting the development of a modular

training program that could be used to train and develop hospital/health system case managers

for entry-level, specialty, and leadership positions. A task force made up of volunteers from the

committee met with Helen McNeal, Ph.D., Executive Director, CSU Institute of Palliative Care

to review curriculum and make suggestions for content.

Based on the input provided by the workgroup, Dr. McNeal and colleagues developed several

outlines for course curriculum, and seeks additional feedback from committee members on

course content.

23

333 S. Twin Oaks Valley Rd • San Marcos, CA 92096-0001 • (760) 750-4006 • www.csupalliativecare.org

Helen B. McNeal Office: (760) 750-7290

Cell: (760) 405-1757 [email protected]

CARE EXCELLENCE Case Management Education

FOUNDATIONAL CASE MANAGEMENT CURRICULUM

I. CASE MANAGEMENT PRINCIPLES: THEORY AND PRACTICE A. Care Management Concepts

1) History of Care Management a) 1869-1982

i) Case Work The Charity Organization Society ii) Contributing Factors to Case Work iii) Purpose of Case Work iv) Outcome of Case Work

b) 1955-1979 i) Case Workers evolved to Case Managers ii) Contributing Factors to Case Management iii) Purpose of Case Management iv) Outcome of Case Management

c) 1980-2012 i) Case Managers evolved to Care Managers+ ii) Contributing Factors to Care Management iii) Purpose of Case Management iv) Outcome of Case Management

2) Case Management Building Blocks a) Risk Assessment

i) Number of Days to Discharge ii) Appeals and Denials iii) Transition Care iv) Assessing Functional Status and Performance

(1) Assessing Comorbidities (2) Knowledge of Illness (3) Readiness for Education (4) Motivational Interviewing (5) Family Involvement (6) Management of ADL’s and IADLs (7) DME Requirements

v) Managing and Coordinating Care for Multiple Chronic Conditions

25

2

(1) Home Environment (2) Transportation (3) Safety evaluation

b) Plan/Coordinate i) Plan for Day/Plan for Stay ii) Plan for Discharge Rounds iii) MCG Pathways/Status Levels iv) Quality

(1) Access (2) Defining Concepts (3) Barriers to Access (4) Results of Barriers to Access (5) Responsiveness (6) Principles for Member-centered care

v) Managing Multiple Providers (1) Care Coordinator/Care Manager Assistance (2) Managing Appointments

(a) Care Management Involvement (b) Empowering patient and family (c) When to involve Field Care Managers

vi) Best Practices for Appointment Preparation: (1) Journaling patient’s experience with treatment-What has worked, what has not, options

for change (2) Documenting questions/concerns with patient for MD appointment

vii) Best Practices Appointment Follow up (1) Review appoints, medical tests, medications, medications prescribed, screenings,

surgical options, costs and follow-up required (2) Providing instructional tools and support post appointment

viii) Collaboration with Pharmacy (1) Medications Requirements for Chronic Illnesses (2) Understanding Side Effects (3) Medication Interactions and Storage Issues (4) Medication Considerations for Specific Needs

(a) Visual Concerns-Large Print Labels (b) Swallowing, Crushable, and Injections (c) Other Risk Factors-Fall Risk, Allergic Reactions, Access

c) Discharge i) Best Practices for discharging different levels of care ii) Establishing Realistic, Measurable, and Attainable Goals iii) Maintaining Care Plan Flexibility iv) Engaging Family v) Coordination of Medical and Behavioral Treatments

(1) Identify Medical Needs

3

(2) Adherence (3) Behavior treatment (4) Medications (5) Education (6) Support (7) Resources

vi) Coordination of Medical and Long Term Services and Support (2 CE hours) (1) Understanding the Various Types of Living Arrangements

(a) (home, board & care, assisted living, home health, SNF, etc) (2) Defining Long Term Services and Support (3) Qualifying services

(a) What does home bound mean? (b) Requirements for Stay: LTAC vs. SNF vs. Acute Rehab

(4) Type of facilities for LTSS (5) Type of specialty care at facility (6) Multidisciplinary Approach

3) Care Management Function and Driving Forces a) Professional Designations (RN, LVN, UR, Discharge, ED, etc) b) Professional Roles and Responsibilities c) Understanding Work Flow d) Nurse vs. Case Manager e) Public Health Models

i) ACO Environmental Structure ii) Medicare Health Survey Plus iii) Population Health Management

B. Principles of Practice

1) Ethics a) Defining Concepts b) Principles and Relationships-Transference and Countertransference c) Principles and Relationships-Advocacy of Patients/Protecting Revenue d) Principles and Practice-Value Conflict Awareness e) Best Practices for Value Conflict Prevention f) Practicing Motivation through Values g) Principles of Ethics h) Patient Rights/Patient Choice i) Informed Consent j) Confidentiality k) HIPPA, Liability, and Avoiding Mistakes l) Cultural Humility Competence m) EMTALA n) Populations with Transmittable Diseases

2) Working across Disciplines Professions

27

4

a) Other Disciplines (PA, CMO, Beside RN, CNO, Other) b) Liaisons on Campus c) Health Plans (Risk vs. Quality) d) Managing difficult conversations

3) Interventions for Positively Modifying Behavior a) Communication and Sharing: Bedside Conversations b) Conflict Management c) Aligning with Alternate Treatments d) Empowerment: CM and Patient e) Prioritizing a Day

4) Models of Care a) Chronic Model b) Guided Model ?? c) Coleman Model ?? d) Transitional Model

5) Understanding and Interpreting Written Communication a) The Value of Understanding and Interpreting Written Communication b) Techniques for Writing that are Concise and Objective c) Techniques for Legally Defensive Writing d) Tell an Accurate Story: Avoid Cut/Paste e) Meaningful Writing: Open Medical Record

C. Healthcare Management and Delivery

1) Evolution of Health Care a) From domestic medical care to science and technology b) Fee for service to Outcome driven c) Capitation and risk‐ value based d) Bundling e) DRGs f) Inpatient vs. Outpatient g) Risk Arrangements h) The Triple Aim i) Quality Effects/Patient Satisfaction

2) The Health Care Sector a) Individual primary care provider b) Physicians/Medical groups c) Hospitals d) Rural Health Clinics e) LTACF f) SNFs g) Assisted Living/Board and Care h) Homecare i) Telehealth

5

j) Acute Care Rehab k) Behavior Health l) Health Plans m) Federal and State Government (Medicare/Medicaid)

3) Trends Influencing Health Care Today a) Growth of the Health Care Sector b) Increased Life Expectancy c) Health Care Workforce Shortages d) Changing Economics of Health Care e) Underinsured/Uninsured f) Staff Models g) IPA h) Changing Roles of Health Professions i) Affordable Care Act j) High Deductible Care Plans k) Population Health Management l) Increased Need for Communication

4) Managed Care a) Principles

i) Optimizing health through prevention ii) Reducing overutilization/underutlization iii) Greater consistency and quality of care

b) Structures i) HMO ii) PPO

5) Types of Health Care Coverage a) Employer b) Private Pay c) Veterans Administration (VA) d) Medicaid (Medi‐Cal in California) e) Medicare “donut hole” f) Dual Eligibles

6) Care Management Opportunities and Outcomes a) Assessment and care planning

i) Goals‐ person vs the health care delivery system ii) Informed decision making

b) Care Coordination and integration i) Medical and social services ii) Community services and resources iii) Promotion and Prevention iv) Reaching out to health plan offerings

c) Outcome‐ Triple Aim

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6

D. Legal Issues and Hospitals: Acts, Regulations, Laws, and Accreditations 1) Legal Issues and Hospitals 2) Acts

a) Emergency Medical Treatment and Labor Act (EMTALA) b) Patient-Family Caregiver Act

3) Regulations c) CMS

i) Non-coverage letters ii) Informed Choice iii) Informed Consent

d) Discharge Regulations 4) Laws

e) Mandatory Reporting i) Defining Mandatory Reporting ii) Mandatory Reporting of Child Abuse iii) Mandatory Reporting of Dependent Adult and Elder Abuse

f) Capacity, Guardianship, and Conservatorship i) Profiles of Protected Populations vs. Vulnerable Populations ii) Capacity iii) Guardianship iv) Conservatorship v) The “Legality” of Working with Protected and Vulnerable Populations

5) Accreditation g) JCAHO h) NCQA i) HFAP

E. Peer Support, Burnout Prevention, and Safety

1) Peer Support Groups a) Defining Concepts of Peer Support b) Maintaining Successful Peer Support Groups c) Corollaries of Peer Support Groups d) Organizational Support Groups e) Professional Support Groups

2) Burnout Prevention a) Defining Concepts of Burnout b) Contributors of Burnout c) Signs and Symptoms of Burnout d) Neutralizing Burnout e) Recovering Coping with Burnout f) Physical Health Resilience Tactics to Prevent Burnout g) Emotional Health Resilience Tactics to Prevent Burnout

3) Civility

7

a) What is civil behavior? b) What is not civil behavior? c) Self-Assessment

F. Critical Thinking

1) Sound Critical Judgement 2) Following Clinical Pathways 3) Critical Thinking for Communicating 4) Critical Thinking for Documentation 5) Hand Overs/Hand Offs Communication (SBARS) 6) Identification of High Risk Members 7) Forecasting and Strategizing High Level Needs 8) Qualitative Treatment 9) Managing Complex Personalities, Prognosis, Utilization Patterns, and Crisis II. MOTIVATIONAL INTERVIEWING

A. Motivational Interviewing Concepts 1) Self-Assessment 2) Defining Motivation 3) Motivation and Culture 4) Choices 5) Defining Motivational Interviewing 6) The Case for Motivational Interviewing 7) Limitations of Motivational Interviewing

B. The Spirit of Motivational Interviewing 1) Aligning Motivational Interviewing with Healthcare 2) Ineffective Motivational Techniques 3) Dynamics to Watch Out For

C. Applying Motivational Interviewing 1) Motivational Interviewing Language 2) Motivational interviewing Techniques 3) OARS 4) Affirmations 5) Reflections 6) Menu of Options 7) Rolling with Resistance 8) Developing Discrepancies 9) Decisional Balance 10) Additional Motivational Interviewing Strategies 11) Motivational Interviewing for Exploring Person-Centered III. RELATIONSHIP BUILDING

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8

A. Interdisciplinary Care Teams 1) Understanding Interdisciplinary Care Teams

a) History of Team Practice Models b) Care Teams Approaches c) Purpose of Interdisciplinary Care Teams d) Barriers/Challenges to Interdisciplinary Care Teams e) Overcoming Barriers/Challenges to Interdisciplinary Care Team f) Elements for a Successful Interdisciplinary Care Team

2) Key Professional Roles a) The Primary Cohort of Professionals within Interdisciplinary Care Teams b) Hospitalists/Attending, Pharmacy, Dietician, PT/ST/OT, Bedside RN, Social Work, PC/Hospice,

Home Care, Rehab c) The Supporting Medical Professionals of Interdisciplinary Care Teams d) Composition, Size, and Leadership within Interdisciplinary Care Teams e) Structure/Function of IDTs in Hospital f) Huddles vs. Floor Teams; How to be the leader of the conversation; Goals/Anticipated

outcomes for discharge specifically 3) Communication and Collaboration

a) Communication versus Collaboration b) Communication and Collaboration: The First Steps c) The Complexity of Communication d) Awareness and Flexibility of Communication Needs e) Incorporating Civility f) Characteristics of Collaboration in Interdisciplinary Care Teams

4) Conducting Interdisciplinary Care Team Meetings a) Time Management b) Providing Concise Information/Focus on MDR c) Discharge Barriers/Updates d) What to take on-line/off-line?

B. Patient-Family-Caregiver Engagement Principles

1) Defining Concepts a) What is Patient Engagement? b) Self-Efficacy vs. Patient Engagement c) Health Literacy vs. Patient Engagement d) Patient Engagement and Person-Centered Care

2) Models and Measurements a) Patient Engagement: A Professional Model b) Patient Engagement: A Patient Framework c) Patient Activation Measurement (PAM) d) PAM Application: Diversity, Demographics, Diagnoses e) PAM Levels of Activation

3) Significance of Patient Engagement

9

a) Impacts of Low Engagement vs. High Engagement b) Patient Engagement and Health Outcomes c) Patient Engagement and Health Care Experience d) Patient Engagement and Health Cost e) Impact of Patient Engagement on Care Managers f) Impact of Patient Engagement on Medical Systems

4) Initiating and Sustaining Patient Engagement a) Initiating Patient Engagement b) Barriers to Patient Engagement c) Transitioning Patients: Passive Recipients to Active Participants d) Intervening to Increase Engagement e) Transitioning Clinical Perspectives

5) Initiating and Sustaining Family Engagement a) Creating Appropriate Handovers of Care b) Assessing Willingness to Learn and Do c) Education Requirements d) Using Translators for Non-English Speakers

C. Provision of Resources: Community Support and Advocacy

1) What is Community Support? 2) What is Advocacy? 3) The Role of Community Support and Advocacy in Care Planning 4) Identification and Verification of Resources 5) Accessibility of Resources 6) Diversification of Resources 7) Sustaining Meaningful Relationships across Resources IV. COMPLEX CARE COORDINATION SKILLS

A. Advance Care Planning 1) Advanced Care Planning Principles 2) Communicating Advanced Care Planning 3) Advanced Directives 4) Powers of Attorney 5) POLST

B. Palliative Care C. Hospice and End of Life Planning D. Improving Transitional Care E. Inter-Agency and Multi-Program Coordination F. Evaluating Meaning in Communication

1) Key Elements of Meaningful Communication 2) Understanding and Interpreting Verbal Communication 3) Understanding and Interpreting Non-verbal Communication

G. Assessing Capacity and Literacy

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1) Understanding Capacity a) What is capacity b) Capacity vs. Competency and Autonomy c) Breaking Down the Components of Capacity d) Conditions for Capacity Concerns e) When Questions of Capacity are Treatable

2) Determining Capacity a) Who Determines Capacity? b) Assessment Tools for Capacity-Interviewing c) Assessment Tools for Capacity-Formal Testing d) Post Lack of Capacity Determinations

3) Understanding Literacy a) What is Literacy? b) Improving Literacy

4) Understanding Health Literacy a) Definitions of Health Literacy b) Data on Adult Health Literacy and Numeracy in the US c) Why is Health Literacy Important? d) Who is at Risk for Lower Health Literacy? e) How to Improve Health Literacy H. Diverse Populations Overview

1) Introduction to Special Populations a) Definition of Special Populations b) Significance of Special Populations in healthcare

2) Overview of special populations a) Mental Illness

i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

b) Homelessness and Poverty i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

c) Substance Abuse i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

11

d) Pain Management and Chronic Opioid Abuse i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

e) Domestic Violence i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

f) Jail and Forensic Health i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

g) People with physical disabilities i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

h) Intellectual and developmental disabilities i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

i) LGBTQ i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

j) Alzheimer’s/Dementia i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

k) TBI/ABI

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12

i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

l) Transplant i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

m) Pediatrics i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study

n) Farm Worker/Immigrant Populations i) Definition ii) Prevalence iii) Common barriers to care iv) Resources v) Case Study





FOUNDATIONAL UTILIZATION REVIEW CURRICULUM






2) Utilization Management/Utilization Review a) Utilization Management

i) Defining Concepts: Structure and Function (payer detail, Medicare vs. Commercial Insurance, Observation vs. Inpatient, Condition Code 44) ii) Categories iii) Goals iv) Resource Management

b) Utilization Review i) Defining Concepts (Why do we do UR? What is its Purpose? What is medical criteria? Denials-what are they? How they are handled?; Appeals--what are they? How they are handled) ii) Use of PA iii) Triggers for Review

37

2

iv) Identification of High Rik Patients v) Predicting Discharge Date vi) UR Committee/Joint Operations Committee vii) Understanding Levels of Care (Acute vs. Admin; ICU vs. Surgical days; Planned vs. Emergent Hospitalization) viii) Platforms for Work vs. Support Tools (Allscripts, Epic, MCG decision making tools)

c) Risk Management i) Defining Payer Quality Review ii) Quality/Core Measures iii) Readmission Rates iv) Avoidable Days/Saved Days v) Variance Days vi) Third Party Reviews and Regulations

d) Care Management Function and Driving Forces i) Professional Designations (RN, LVN, UR, Discharge, ED, etc) ii) Professional Roles and Responsibilities iii) Understanding Work Flow iv) Nurse vs. Case Manager v) Public Health Models

(1) ACO Environmental Structure (2) Medicare Health Survey Plus (3) Population Health Management



2) Protected vs. Vulnerable Populations a) Profiles of Protected Populations b) Profiles on Vulnerable Populations

3

c) The “Legality” of Working with Protected and Vulnerable Populations 3) Working across Disciplines Professions







2) The Health Care Sector a) Individual primary care provider b) Physicians/Medical groups c) Hospitals d) Rural Health Clinics e) LTACF f) SNFs g) Assisted Living/Board and Care

39

4

h) Homecare i) Telehealth j) Acute Care Rehab k) Behavior Health l) Health Plans m) Federal and State Government (Medicare/Medicaid)









5












2) Burnout Prevention a) Defining Concepts of Burnout b) Contributors of Burnout c) Signs and Symptoms of Burnout d) Neutralizing Burnout e) Recovering Coping with Burnout f) Physical Health Resilience Tactics to Prevent Burnout

41

6

g) Emotional Health Resilience Tactics to Prevent Burnout 3) Civility



1) Sound Critical Judgement 2) Following Clinical Pathways 3) Critical Thinking for Communicating 4) Critical Thinking for Documentation 5) Hand Overs/Hand Offs Communication (SBARS) 6) Identification of High Risk Members 7) Forecasting and Strategizing High Level Needs 8) Qualitative Treatment 9) Managing Complex Personalities, Prognosis, Utilization Patterns, and Crisis

G. Interdisciplinary Care Teams 1) Understanding Interdisciplinary Care Teams






4) Conducting Interdisciplinary Care Team Meetings a) Time Management

7

b) Providing Concise Information/Focus on MDR c) Discharge Barriers/Updates d) What to take on-line/off-line?

43





FOUNDATIONAL UTILIZATION REVIEW CURRICULUM






2) Utilization Management/Utilization Review a) Utilization Management

i) Defining Concepts: Structure and Function (payer detail, Medicare vs. Commercial Insurance, Observation vs. Inpatient, Condition Code 44) ii) Categories iii) Goals iv) Resource Management

b) Utilization Review i) Defining Concepts (Why do we do UR? What is its Purpose? What is medical criteria? Denials-what are they? How they are handled?; Appeals--what are they? How they are handled) ii) Use of PA iii) Triggers for Review

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2

iv) Identification of High Rik Patients v) Predicting Discharge Date vi) UR Committee/Joint Operations Committee vii) Understanding Levels of Care (Acute vs. Admin; ICU vs. Surgical days; Planned vs. Emergent Hospitalization) viii) Platforms for Work vs. Support Tools (Allscripts, Epic, MCG decision making tools)

c) Risk Management i) Defining Payer Quality Review ii) Quality/Core Measures iii) Readmission Rates iv) Avoidable Days/Saved Days v) Variance Days vi) Third Party Reviews and Regulations

d) Care Management Function and Driving Forces i) Professional Designations (RN, LVN, UR, Discharge, ED, etc) ii) Professional Roles and Responsibilities iii) Understanding Work Flow iv) Nurse vs. Case Manager v) Public Health Models

(1) ACO Environmental Structure (2) Medicare Health Survey Plus (3) Population Health Management



2) Protected vs. Vulnerable Populations a) Profiles of Protected Populations b) Profiles on Vulnerable Populations

3

c) The “Legality” of Working with Protected and Vulnerable Populations 3) Working across Disciplines Professions







2) The Health Care Sector a) Individual primary care provider b) Physicians/Medical groups c) Hospitals d) Rural Health Clinics e) LTACF f) SNFs g) Assisted Living/Board and Care

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4

h) Homecare i) Telehealth j) Acute Care Rehab k) Behavior Health l) Health Plans m) Federal and State Government (Medicare/Medicaid)









5












2) Burnout Prevention a) Defining Concepts of Burnout b) Contributors of Burnout c) Signs and Symptoms of Burnout d) Neutralizing Burnout e) Recovering Coping with Burnout f) Physical Health Resilience Tactics to Prevent Burnout

49

6

g) Emotional Health Resilience Tactics to Prevent Burnout 3) Civility



1) Sound Critical Judgement 2) Following Clinical Pathways 3) Critical Thinking for Communicating 4) Critical Thinking for Documentation 5) Hand Overs/Hand Offs Communication (SBARS) 6) Identification of High Risk Members 7) Forecasting and Strategizing High Level Needs 8) Qualitative Treatment 9) Managing Complex Personalities, Prognosis, Utilization Patterns, and Crisis

G. Interdisciplinary Care Teams 1) Understanding Interdisciplinary Care Teams






4) Conducting Interdisciplinary Care Team Meetings a) Time Management

7

b) Providing Concise Information/Focus on MDR c) Discharge Barriers/Updates d) What to take on-line/off-line?

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LEADERSHIP CURRICULUM

I. Best Practices for Improved Outcomes (8 CE Hours) 1) Collaboration and Brainstorming

a) Motivating Collaborative Participation i) Support ii) Skills

b) Understanding and Practicing Brainstorming i) Ideas-Good, Bad, and Ugly ii) Promoting Idea Development and Sharing iii) Creating Individualized Plans

c) Resource Development i) Identification ii) Safety in Sharing iii) Relationship Building across Resources

2) Understanding and Utilizing Quality and Performance Standards Data a) Understanding Quality Performance Standards

i) Outcomes ii) Patient/client Satisfaction iii) Functional Status iv) Cost Effectiveness.

b) Utilizing Quality Performance Standards i) Professional Development ii) Quality Improvement

3) Problem Solving and Critical Thinking a) Problem Solving

i) Problem Identification ii) Decision Making Strategies iii) Creativity and Alternatives

b) Critical Thinking in Practice i) Practicing Self-Disciplined Reasoning ii) Socratic Questioning iii) Cultivating an Attitude of Inquiry iv) Engaging Reflective Thinking

4) Communication: Open Dialogue and Cross Discipline Learning

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2

a) Improving Communication with Care Managers b) Encouraging Open Dialogue with Clients c) Building Cross Discipline Interaction d) Promoting Cross Discipline Learning

3

II. Mentorship (8 CE Hours) 1) Knowledge Mentoring vs. Wisdom Mentoring

a) What is Knowledge Mentorship b) What is Wisdom Mentorship c) Cultivating a Knowledge and Wisdom Mentorship Environment

2) Bi-Directional Mentoring a) What is bi-directional mentoring b) Benefits of bi-directional mentoring c) Cultivating a Bi-directional Mentorship Environment

3) Creating Assurances for Success a) Getting to Known Your Staff

i) Identifying strengths ii) Determining weaknesses iii) Creating opportunities for alternative mentoring partnerships

b) Benefits of Open Door Policies c) The Telephonic Mentorship Paradigm

i) Identifying strengths ii) Determining weaknesses iii) Creating opportunities for alternative mentoring partnership

4) Informal vs. Formal Mentoring a) What is Informal Mentorship b) What is Formal Mentorship c) Promoting Mentorship Partnerships in any form.

5) Role Modeling a) Walking the Talk b) Walking the Walk

III. Leadership(8 CE Hours) A. Influence, Power, and Persuasion (1.5 hours)

1) How do influence, power and persuasion work in leadership? 2) What is Leadership?

a) Myths b) Reality c) Leadership Components

3) Developing Leadership Skills a) Building technical competence b) Fostering effective relationships

i) Superiors ii) Peers iii) Those Supervised

c) Building credibility, expertise, and trust d) Reaching beyond the comfort zone

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4

e) Learning from experience i) Be open to receiving feedback from others ii) Create a self-development plan

B. Hiring Practices: Screening for Potential (1.25 hours) 1) Essential Skills for Care Managers

a) Essential Roles i) Educator ii) Coordinator and Collaborator iii) Communicator and Transition Planner iv) Clinician and Leadership v) Negotiator and Advocate

b) Essential Skills and Abilities 2) Assessing for Potential

a) Hiring Practices for Success b) Avoiding Hiring Headaches c) High Potential Employees d) Qualities of a Good Hire e) Building Your A-Team f) High-Performers vs. High-Potentials g) Encouraging Professional Potential

3) Value of Critical Thinking a) What is Critical Thinking b) Qualities of a Critical Thinker c) Process of Critical Thinking d) Strategies for Evaluating Critical Thinking Skills e) Creative Critical Thinking Activities

4) Evaluating Values, Reactions, and Adaptability a) Demonstrating Values and Reactions b) Core Values and Reactions c) Adaptability in the Workplace d) Developing Agility and Adaptability Skills e) Benefits of an Agile Workplace C. Improving Job Satisfaction and Reducing Turnover (1.25 hours)

1) Understanding Care Manager Needs a) Care Manager Needs b) Leadership Potential: Self Analysis c) Behaviors for CM Leaders d) Skills of CM Leaders e) The Importance of Emotional Intelligence f) Improving Job Satisfaction

2) Provide Consistent Constructive Feedback a) What exactly is Feedback? b) What do we know about Feedback?

5

c) Situations for Constructive Feedback d) When Constructive Feedback is Required e) Making Feedback Constructive f) Steps for Giving Constructive Feedback g) The Sandwich Method

3) Create Opportunities for Empowerment a) Employee Empowerment b) Benefits of Employee Empowerment c) Tips for Empowering CMs d) Sustaining Empowerment e) Empowering Qualities in Hiring

4) Strategies for Reducing Turnover a) Impact of Turnover b) Recruiting Strategies c) Post-Hire Strategies D. Provisions for a Supported Care Manager (2 hours)

1) Enhancing Resilience a) Importance of Resilience b) Promoting Emotional Resilience c) Promoting Physical Resilience

2) Promote Stress Management a) Triggers b) Thinking and Feelings c) Reactions

3) Reducing Burnout a) Recognizing Burnout b) Assessing Contributors within the Work Environment c) Neutralizing Burnout Contributes d) Encouraging Healthy Outlets e) When Burnout Occurs…. E. Creating a Culture of Learning and Growth (1 hour)

1) Peer Support, Mentorship Programs, Reflective Partners a) Starting and Maintaining Successful Support Groups b) Benefits of Mentoring c) Supporting Reflective Partnerships

2) Promoting Learning a) Identifying Education Needs b) Encouraging Questions/Promoting Safe Learning Environments c) Informal Learning Program d) Formal Education Programs F. Leadership in Practice (1hour)

Note: Create a case study/scenario with good, bad, and indifferent employees and supervisors. Have small groups play out scenarios with facilitator observation. Facilitators will randomly

57

6

throw in “curveballs” for both employees and supervisors to enhance critical thought and action in role plays and to reinforce learning points from the day.

IV. INNOVATION A. Fostering Innovation

1) Meaning and Importance in Case Management a) Characteristics of Innovation b) Phases of Innovation c) Framework for Leading Innovation

2) Enhancing Innovation Internally a) Promoting Innovation for Individuals and Teams b) Quality Performance Improvements c) Promoting and Innovative Culture

3) Enhancing Innovation Externally a) Clients, Customers, and other Stakeholders b) Community Partnerships c) Impacting Industry Innovation d) Contributing to Professional Innovation B. Education

1) Innovative Internal Education a) Informal Education Options b) Formal Education Options c) Building an Internal Education Program

2) Innovative External Education a) Overcoming Barriers b) Benefits c) Evaluating External Education Options d) Credentials: Benefits and Opportunities C. Resource Advocacy

1) Individual Resource Development Strategies a) Inspiring Creativity and Innovation b) Promoting and Sustaining Innovation c) Networking for Improved Resource Development

2) Organizational Resources a) Identifying Viable Resources b) Sharing Across the Organization c) Housing and Maintaining Real Time Resources

3) Community Partners a) Profile of Community Partnerships

i) Why Community Partnerships? ii) Types of Partnerships iii) Professional/Organizational Benefits of Community Partnerships iv) Consumer, Constituent and Community Benefits of Community Partnerships

7

v) Challenges of Community Partnerships vi) Overcoming Challenges of Community Partnerships vii) Characteristics of Successful Community Partnerships viii) 10 Reasons to Form Community Partnerships

b) Identifying Viable Community Partnerships i) Private Partnerships Diversification ii) Potential Partnership Stakeholders iii) Internal Variables to Consider iv) Aligning Community and Program Needs v) External Considerations for Assessing Potential Partners

c) Creating win-win relationships i) Formalizing the Community Partnership and Setting Parameters ii) The First Community Partnership Meeting iii) Initiating Community Interaction-Post Partnership iv) Creation and Implementation Phase of Service

D. Innovative Collaboration (1.5 hours) 1) Defining Innovative Collaboration

a) What is Innovative Collaboration? b) Benefits of Innovative Collaboration c) Barriers to Innovative Collaboration d) Overcoming Barriers to Innovative Collaboration

2) Types of Innovative Collaboration a) Top Down Models b) Peas in a Pod c) Partners in Crime d) Challengers

3) Tools for Innovative Collaboration a) Challenge Mapping b) Strategy Shaping c) Matchmaking d) Empathizing with Users e) Collaboration Networking and Collaboration Colloquium

4) Innovative Collaboration In Practice Note: Create several scenarios, both CM related and Leadership/Employee related. Participants will work in small groups, and groups will be tasked with applying concepts learned from the day’s lessons to develop innovative solutions to issues presented. An emphasis will be placed on the application of types of Innovative Collaboration and Tools for Innovative Collaboration.

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January 25, 2017


FROM: Debby Rogers, VP Clinical Performance and Transformation

SUBJECT: Medicare Outpatient Observation Notice (MOON) and State Observation

Requirements Operational Issues/Questions

SUMMARY

Beginning January 8, 2017, the Centers for Medicare & Medicaid Services (CMS) requires

hospitals and CAHs to provide all Medicare eligible patients who receive outpatient observation

services for more than 24 hours with a written Medicare Outpatient Observation Notice (MOON)

(attached) and oral notification. Federal law requires that notification be given within 36 hours

after observation services are initiated, or sooner if the individual is transferred, discharged or

admitted as an inpatient. The notice informs patients that they are an outpatient receiving

observation services, are not an inpatient, and outlines the associated implications for cost-

sharing and eligibility for Medicare coverage of skilled-nursing facility (SNF) services.

Specifically, the MOON:

Explains that the individual is an outpatient—not an inpatient, using an open text box for the

hospital to insert the specific reason the person is not an inpatient

Explains the implications of receiving observation services as an outpatient, such as

Medicare cost-sharing requirements and eligibility for SNF care

Provides the forms in English and Spanish

Includes a blank section that a hospital may use for additional information

Includes a dedicated signature area for patients or representatives to acknowledge receipt and

understanding of the notice

In the case of where the individual is admitted as an inpatient but following internal utilization

review (UR) performed while the patient is hospitalized, the hospital determines that the services

do not meet its inpatient criteria and the physician concurs with UR and orders the

discontinuation of inpatient services and initiation of outpatient observation services (that is, a

Condition Code 44 situation), the MOON would be delivered as required by the NOTICE Act

(when outpatient observation services have been ordered and furnished for more than 24 hours).

In cases where a CMS reviewer denies a claim for inpatient services as not medically reasonable

and necessary, CMS clarifies that there would be no requirement to issue a MOON; the same

policy applies where a hospital under its own utilization review (after a beneficiary is

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Observation Notification

January 25, 2017

Page 2

discharged) determines the inpatient admission is not medically reasonable and necessary and

bills for the services under Part B. In both cases, the patient’s status remains ‘inpatient.’

In addition, SB 1076, signed by Governor Brown, requires hospitals to provide a written notice

to a patient on observation status who is cared for in a hospital’s inpatient unit or in an

observation unit, or following a change in a patient’s status from inpatient to observation. The

notification must be provided as soon as practicable, beginning January 1, 2017 (attached). The

state law requires the notice to state that while on observation status, the patient’s care is being

provided on an outpatient basis, which may affect his or her health care coverage reimbursement,

but does not mandate a specific form. CHA has not identified conflicts between the state and

federal requirements.

SB1076 allows for the designation and use of Observation Units for the first time. Many

hospitals have developed clinical decision units, or ED adjacent units to care for patients on

observation status, but this was not specifically permitted in state law before now. Hospitals

choosing to establish an Observation Until must have OSHPD and CDPH approval, post

appropriate signage and staff the unit at the ED staffing ratio. In addition, hospitals will be able

to care for patients on observation status on inpatient units, a practice that has been used for

decades, but was not formally permitted in the law before now.

Observation Services Notification —

New State and Federal Requirements Webinar

Complying with CMS' MOON and California's SB 1076

Register now

February 14, 2017

10:00 a.m. – 12:00 p.m., PT

As of Jan. 1, SB 1076 requires hospitals to provide a written notice to certain patients receiving

observation services. Beginning March 8, CMS will require hospitals to provide the Medicare

Outpatient Observation Notice (MOON) and verbal notification to Medicare beneficiaries

receiving outpatient observation services.

Both state and federal notice requirements pose significant challenges. What to include in your

P&Ps, documentation, and management of patient questions and disagreements are a few of the

issues hospitals must address to comply. Make plans to participate now and learn how to manage

these and other facets of the new requirements.

Recommended for:

Health care professionals including: chief medical officers, chief nursing officers, in-house

general counsel, compliance officers, case managers, emergency department staff, discharge

planners, and licensing and accreditation professionals.

To register, go to www.calhospital.org/observation-services-notification-web

http://www.calhospital.org/observation-services-notification-web


January 25, 2017

Page 3

Agenda

CMS’ Medicare Outpatient Observation Notice (MOON) and New State Law SB 1076

• Defining observation services

• Written and verbal notifications

• State vs. federal timelines for informing patients

• Which patients must receive notification

• Requirements of dedicated observation units

Crosswalk: State vs. Federal Requirements

The Law in Practice — Operational Considerations

• Developing policies and procedures

• Notification responsibilities and procedures

• Responding to patient questions, disagreements

• Documentation and recordkeeping

• Translation and interpreter requirements

• Combining state and federal forms, or keep separate

• MOON form and free text area

To register, go to www.calhospital.org/observation-services-notification-web

Presenters

From the California Hospital Association:

Debby Rogers, RN, MS, Vice President, Clinical Performance and Transformation

Patricia Blaisdell, FACHE, Vice President, Continuum of Care

Tuition

*Members $185

**Nonmembers $250

*Members are CHA member hospitals, CHA associate members and government agencies.

**Nonmembers are limited to non-hospital health care providers, clinics, post-acute facilities,

and consultants, insurance companies, law firms and other entities that serve hospitals. Education

programs and publications are a membership benefit and are not available to eligible nonmember

California hospitals.

Continuing Education

Continuing education will be offered (or application has been made) for the following:

Compliance, Health Care Executives, Legal and Nursing.

Need More Information?

Visit the web page at www.calhospital.org/observation-services-notification-web or call the

CHA Education Department at (916) 552-7637.

ACTION REQUESTED:

Please be prepared to discuss implementation and operational issues, and unresolved questions

with committee. Please be prepared to discuss any internal work at your organization has done

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January 25, 2017

Page 4

on implementation and challenges, solutions and/or outstanding questions. Some questions that

have been asked include:

Which staff should is best to give the written/oral notification

Which staff is best to address patient questions/provide answers

What is the best time to give the notification

What type of documentation is needed for medical records

Can a behavioral health patient be placed on observation servies

How does the patient appeal

DR:br

Medicare Outpatient Observation Notice Patient name: Patient number:

You’re a hospital outpatient receiving observation services. You are not an inpatient because:

Being an outpatient may affect what you pay in a hospital:

• When you’re a hospital outpatient, your observation stay is covered under Medicare Part B.

• For Part B services, you generally pay: o A copayment for each outpatient hospital service you get. Part B copayments may

vary by type of service.

o 20% of the Medicare-approved amount for most doctor services, after the Part B deductible.

Observation services may affect coverage and payment of your care after you leave the hospital:

• If you need skilled nursing facility (SNF) care after you leave the hospital, Medicare Part A will only cover SNF care if you’ve had a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day the hospital admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged.

• If you have Medicaid, a Medicare Advantage plan or other health plan, Medicaid or the plan may have different rules for SNF coverage after you leave the hospital. Check with Medicaid or your plan.

NOTE: Medicare Part A generally doesn’t cover outpatient hospital services, like an observation stay. However, Part A will generally cover medically necessary inpatient services if the hospital admits you as an inpatient based on a doctor’s order. In most cases, you’ll pay a one-time deductible for all of your inpatient hospital services for the first 60 days you’re in a hospital.

If you have any questions about your observation services, ask the hospital staff member giving you this notice or the doctor providing your hospital care. You can also ask to speak with someone from the hospital’s utilization or discharge planning department.

You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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Your costs for medications: Generally, prescription and over-the-counter drugs, including “self-administered drugs,” you get in a hospital outpatient setting (like an emergency department) aren’t covered by Part B. “Self- administered drugs” are drugs you’d normally take on your own. For safety reasons, many hospitals don’t allow you to take medications brought from home. If you have a Medicare prescription drug plan (Part D), your plan may help you pay for these drugs. You’ll likely need to pay out-of- pocket for these drugs and submit a claim to your drug plan for a refund. Contact your drug plan for more information.

Please sign below to show you received and understand this notice.

Signature of Patient or Representative Date / Time

CMS does not discriminate in its programs and activities. To request this publication in alternative format, please call: 1-800-MEDICARE or email:[email protected].

If you’re enrolled in a Medicare Advantage plan (like an HMO or PPO) or other Medicare health plan (Part C), your costs and coverage may be different. Check with your plan to find out about coverage for outpatient observation services.

If you’re a Qualified Medicare Beneficiary through your state Medicaid program, you can’t be billed for Part A or Part B deductibles, coinsurance, and copayments.

Additional Information (Optional):


Instructions CMS-10611 OMB expiration: 12-31-2019

Notice Instructions: Medicare Outpatient Observation Notice

Page 1 of the Medicare Outpatient Observation Notice (MOON)

The following blanks must be completed by the hospital. Information inserted may be typed or legibly hand-written in 12-point font or the equivalent.

Patient Name:

Fill in the patient’s full name or attach patient label.

Patient ID number:

Fill in an ID number that identifies this patient, such as a medical record number or the patient’s birthdate or attach a patient label. This number should not be the patient’s social security number.

“You’re a hospital outpatient receiving observation services. You are not an inpatient because:”

Fill in the specific reason the patient is in an outpatient, rather than an inpatient stay.

Page 2 of the MOON

Additional Information:

This may include, but is not limited to, Accountable Care Organization (ACO) information, notation that a beneficiary refused to sign the notice, hospital waivers of the beneficiary’s responsibility for the cost of self-administered drugs, Part A cost sharing responsibilities if the beneficiary is subsequently admitted as an inpatient, physician name, specific information for contacting hospital staff, or additional information that may be required under applicable state law.

Hospitals may attach additional pages to this notice if more space is needed for this section.

Oral Explanation:

When delivering the MOON, hospitals and CAHs are required to explain the notice and its content, document that an oral explanation was provided and answer all beneficiary questions to the best of their ability.

67

Instructions CMS-10611 OMB expiration: 12-31-2019

Signature of Patient or Representative:

Have the patient or representative sign the notice to indicate that he or she has received it and understands its contents. If a representative’s signature is not legible, print the representative’s name by the signature.

Date/Time: Have the patient or representative place the date and time that he or she signed the notice.

69

January 25, 2017



SUBJECT: Discharge Delay Study Results

SUMMARY

California hospitals believe every patient deserves the right care, at the right time, in the right

place. This is consistent with the Triple Aim of improving care for individual patients and

improving outcomes for the whole population while lowering costs. A significant delay in

discharge — defined as a delay greater than seven days in leaving the hospital after

determination that inpatient care is no longer medically necessary — denies these rights to

vulnerable patients. Delayed discharges occur when hospitals are unable to arrange the

appropriate post-hospital services to meet the patient’s needs.

Common barriers to timely discharge to post-hospital services include patient behaviors,

psychiatric conditions with or without substance use disorder (SUD) and homelessness. This

finding challenges the Institute of Medicine ‘Six Aims’ which calls for health care to be safe,

effective, patient-centered, timely, efficient, and equitable. Equitable health care for patients with

physical health conditions and mental health conditions continues to lag behind the progress

made on the other five aims.

Hospitals often operate at or near full capacity, and delayed discharges contribute to increased

hospital occupancy. Lack of inpatient bed capacity has been cited as a major cause of Emergency

Department (ED) crowding and blocked access to inpatient hospital services.

The CHA Case Management Committee identified delayed discharge as a problem for patients

who are unable to access post-hospital services. The Committee developed a survey and queried

member hospitals in a one-day, point-in-time survey in July 2016 focused on patients whose

inpatient discharge was delayed greater than seven days beyond what was deemed medically

necessary. Seven days was selected as the determining timeframe to eliminate operational

barriers that could delay discharge, such as lack of case management availability at a skilled-

nursing facility or unavailability of transportation.

The study found:

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Discharge Delay

January 25, 2017

Page 2

78 patients were identified as experiencing significantly delayed discharge on the day of

the study; and on average those patients had a 52 day delay in their discharge (median =

17 days).

Patients with significantly delayed discharges often had multiple barriers preventing

discharge placement; 65 percent of these patients had more than one barrier and almost

40 percent had three or more.

On average, hospitals were caring for approximately four patients who no longer needed

inpatient care, but had access barriers to needed post-hospital services. Extrapolated to

the entire state, this means about 1,004 (1.4 percent) patients statewide on any given day

could be receiving inpatient acute care services for seven days or more after

determination that such care was no longer necessary.

Over half (51 percent) of patients with significantly delayed discharge are Medi-Cal

beneficiaries.

The most frequently needed type of facility for delayed discharge patients was skilled

nursing facilities (57 percent), followed by custodial (23 percent), long-term adult care

(16 percent), and behavioral (13 percent).

The single largest barrier to discharge by far was having a behavior-related issue, which

was a barrier for 42 percent of the delayed discharge patients. The next largest barriers

were homelessness and psychiatric/substance abuse disorders, each of which were

barriers for about 26 percent.

Overlap among these top three barriers was common: 55 percent of those with a top

barrier had two or more top barriers. The largest overlaps were among persons with both

behavioral and psychiatric issues (20 percent), those with behavioral issues who were

also homeless (13 percent), and persons with all three top barriers (18 percent).

Among the common barriers, caregiver burden was associated with the longest median

delay in discharge (77 days), followed by being undocumented (26 days), behavioral

issues (21 days), age-related barriers (19 days), patient/family disagreement regarding

transition plans (19 days), homelessness (16 days), psychiatric/substance abuse (14

days), and payer issues (10 days).

Median discharge delay increased as a function of the number of barriers with median

delays of 12 days for those with only one barrier, 20 days for those with only two

barriers, and 29 days for those with three or more barriers.

Particularly long median delays in discharge were among those with psychiatric issues

who were also homeless (55 days), followed by those with both behavioral and

psychiatric issues (30 days).

The updated paper will be sent to the Committee under separate cover.

ACTION REQUESTED:

Discuss and advise CHA on the study results and any needed changes in the paper.

DR:br

January 25, 2017



SUBJECT: Residential Care Facilities for the Elderly (RCFE) placement

SUMMARY

The Department of Social Services has substantiated cases wherein General Acute Care Hospital (GACH)

discharge planners placed patients in RCFEs requiring a higher level of care (i.e. skilled nursing). It

appears the discharge planners are using RCFEs on a temporary basis while waiting for an available

Skilled Nursing Facility bed. DSS reported the hospital to CDPH but it is unknown if CDPH has taken

any action. This issue was discussed by the Case Management Committee and additional information was

requested regarding patient conditions that are appropriate for care in an RCFE.

BACKGROUND

Existing Health and Safety Code 1569.47 (a) "Placement agency" means any county welfare department, county social service department, county

mental health department, county public guardian, general acute care hospital discharge planner or

coordinator, state-funded program or private agency providing placement or referral services, conservator

pursuant to Part 3 (commencing with Section 1800) of Division 4 of the Probate Code, conservator

pursuant to Chapter 3 (commencing with Section 5350) of Part 1 of Division 5 of the Welfare and

Institutions Code, and regional center for persons with developmental disabilities which is engaged in

finding homes or other places for the placement of elderly persons for temporary or permanent care.

(b) A placement agency shall not place individuals in licensed residential care facilities for the elderly

when the individual, because of his or her health condition, cannot be cared for within the limits of the

license or requires inpatient care in a health facility. Violation of this subdivision is a misdemeanor.

The only exception to placing someone with a higher level of need in an RCFE, is if the facility has been

approved for the Assisted Living Wavier (ALW) Program through the Department of Health Care

Services, and the resident has also been approved for the waiver (link

http://www.dhcs.ca.gov/services/ltc/Pages/AssistedLivingWaiver.aspx.

Additional information can be found in the DSS Evaluator Manual –under Residential Care Facilities for

the Elderly ‘Acceptance & Retention Limitations’ at http://ccld.ca.gov/PG546.htm.

DSS Regional Offices may also be of assistance http://ccld.ca.gov/res/pdf/ASC.pdf

The requirements allow an RCFE to provide services through a home health agency under the following

circumstances:

California Health and Safety Code Section 1569.725.

73

http://www.dhcs.ca.gov/services/ltc/Pages/AssistedLivingWaiver.aspx

http://ccld.ca.gov/PG546.htm

https://urldefense.proofpoint.com/v2/url?u=http-3A__ccld.ca.gov_res_pdf_ASC.pdf&d=DQMFAw&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=1IY1Dcni4viNOPjKoAr6Lx_gXEGKZAqn_c4n_G7C2gk&m=jfAW70zf4IKLbcf7ADZj4X77xoH8mYS4zYhv3tIBs6o&s=8MhtO4Iz30Ql2Ko8f6_Yt5Pog3pJhWd2dvQRt2fCBEg&e=

RCFE Placement

January 25, 2017

Page 2

(a) A residential care facility for the elderly may permit incidental medical services to be provided

through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all

of the following conditions are met:

(1) The facility, in the judgment of the department, has the ability to provide the supporting care

and supervision appropriate to meet the needs of the resident receiving care from a home health

agency.

(2) The home health agency has been advised of the regulations pertaining to residential care

facilities for the elderly and the requirements related to incidental medical services being

provided in the facility.

(3) There is evidence of an agreed-upon protocol between the home health agency and the

residential care facility for the elderly. The protocol shall address areas of responsibility of the

home health agency and the facility and the need for communication and the sharing of resident

information related to the home health care plan. Resident information may be shared between

the home health agency and the residential care facility for the elderly relative to the resident’s

medical condition and the care and treatment provided to the resident by the home health agency

including, but not limited to, medical information, as defined by the Confidentiality of Medical

Information Act, Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code.

(4) There is ongoing communication between the home health agency and the residential care

facility for the elderly about the services provided to the resident by the home health agency and

the frequency and duration of care to be provided.

(b) Nothing in this section is intended to expand the scope of care and supervision for a residential care

facility for the elderly, as prescribed by this chapter.

(c) Nothing in this section shall require any care or supervision to be provided by the residential care

facility for the elderly beyond that which is permitted in this chapter.

(d) The department shall not be responsible for the evaluation of medical services provided to the

resident of the residential care facility for the elderly by the home health agency.

(e) Any regulations, policies, or procedures related to sharing resident information and development of

protocols, established by the department pursuant to this section, shall be developed in consultation with

the State Department of Health Services and persons representing home health agencies and residential

care facilities for the elderly.

Health and Safety Code Section 1569.39.

(a) A residential care facility for the elderly that accepts or retains residents with prohibited health

conditions, as defined by the department, in Section 87615 of Title 22 of the California Code of

Regulations, shall assist residents with accessing home health or hospice services, as indicated in the

resident’s current appraisal, to ensure that residents receive medical care as prescribed by the resident’s

physician and contained in the resident’s service plan.

(b) A residential care facility for the elderly that accepts or retains residents with restricted health

conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by

the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals

acting within their scope of practice. An appropriately skilled professional may not be required when the

resident is providing self-care, as defined by the department, and there is documentation in the resident’s

service plan that the resident is capable of providing self-care.

RCFE Placement

January 25, 2017

Page 3

(c) An “appropriately skilled professional” means, for purposes of this section, an individual who has

training and is licensed to perform the necessary medical procedures prescribed by a physician. This

includes, but is not limited to, a registered nurse, licensed vocational nurse, physical therapist,

occupational therapist, or respiratory therapist. These professionals may include, but are not limited to,

those persons employed by a home health agency, the resident, or a facility, and who are currently

licensed in this state.

(d) Failure to meet or arrange to meet the needs of those residents who require health-related services as

specified in the resident’s written record of care, defined pursuant to Section 1569.80, or failure to notify

the physician of a resident’s illness or injury that poses a danger of death or serious bodily harm is a

licensing violation and subject to civil penalty pursuant to Section 1569.49.

(e) This section shall become operative on January 1, 2016.

Title 22 §§ 87609-87617 pertaining to RCFE use of Home Health Agencies

87609. Allowable Health Conditions and the Use of Home Health Agencies.

(a) A licensee shall be permitted to accept or retain persons who have a health condition(s) which requires

incidental medical services including, but not limited to, the conditions specified in Section 87612,

Restricted Health Conditions.

(b) Incidental medical care may be provided to residents through a licensed home health agency provided

the following conditions are met:

(1) The licensee is in substantial compliance with the requirements of Health and Safety Code

Sections 1569-1569.87, and of Chapter 8, Division 6, of Title 22, CCR, governing Residential

Care Facilities for the Elderly.

(2) The licensee provides the supporting care and supervision needed to meet the needs of the

resident receiving home health care.

(3) The licensee informs the home health agency of any duties the regulations prohibit facility

staff from performing, and of any regulations that address the resident's specific condition(s).

(4) The licensee and home health agency agree in writing on the responsibilities of the home

health agency, and those of the licensee in caring for the resident's medical condition(s).

(A) The written agreement shall reflect the services, frequency and duration of care.

(B) The written agreement shall include day and evening contact information for the home health

agency, and the method of communication between the agency and the facility, which may

include verbal contact, electronic mail, or logbook.

(C) The written agreement shall be signed by the licensee or licensee representative, and

representative of the home health agency, and placed in the resident's file.

(c) The use of home health agencies to care for a resident's medical condition(s) does not expand the

scope of care and supervision that the licensee is required to provide.

87611. General Requirements for Allowable Health Conditions.

(a) Prior to accepting or retaining a resident with an allowable health condition as specified in Section

87618, Oxygen Administration - Gas and Liquid; Section 87619, Intermittent Positive Pressure Breathing

(IPPB) Machine; Section 87621, Colostomy/Ileostomy; Section 87626, Contractures; or Section 87631,

Healing Wounds; licensees who have, or have had, any of the following within the last two years, shall

obtain Department approval:

(1) Probationary license;

(2) Administrative action filed against them;

(3) A Non-Compliance Conference as defined in Section 87101(n) that resulted in a corrective

plan of action; or

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RCFE Placement

January 25, 2017

Page 4

(4) A notice of deficiency concerning direct care and supervision of a resident with a health

condition specified in Section 87612, Restricted Health Conditions, that required correction

within 24 hours.

(b) The licensee shall complete and maintain a current, written record of care for each resident that

includes, but is not limited to, the following:

(1) Documentation from the physician of the following:

(A) Stability of the medical condition(s);

(B) Medical condition(s) which require incidental medical services;

(C) Method of intervention;

(D) Resident's ability to perform the procedure; and

(E) An appropriately skilled professional shall be identified who will perform the procedure if the

resident needs assistance.

(2) The names, address and telephone number of vendors, if any, and all appropriately skilled

professionals providing services.

(3) Emergency contacts.

(c) In addition to Section 87411(d), facility staff shall have knowledge and the ability to recognize and

respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as

necessary.

(d) In addition to Section 87463, Reappraisals and Section 87466, Observation of the Resident, the

licensee shall monitor the ability of the resident to provide self care for the allowable health condition and

document any change in that ability.

(e) In addition to Sections 87465(a) and 87464(d), the licensee shall ensure that the resident is cared for in

accordance with the physicians orders and that the resident's medical needs are met.

(f) The duty established by this section does not infringe on the right of a resident to receive or reject

medical care or services as allowed in Section 87468(a)(16).

87612. Restricted Health Conditions.

(a) The licensee may provide care for residents who have any of the following restricted health

conditions, or who require any of the following health services:

(1) Administration of oxygen as specified in Section 87618.

(2) Catheter care as specified in Section 87623.

(3) Colostomy/ileostomy care as specified in Section 87621.

(4) Contractures as specified in Section 87626.

(5) Diabetes as specified in Section 87628.

(6) Enemas, suppositories, and/or fecal impaction removal as specified in Section 87622.

(7) Incontinence of bowel and/or bladder as specified in Section 87625.

(8) Injections as specified in Section 87629.

(9) Intermittent Positive Pressure Breathing Machine use as specified in Section 87619.

(10) Stage 1 and 2 pressure sores (dermal ulcers) as specified in Section 87631(a)(3).

(11) Wound care as specified in Section 87631.

87613. General Requirements for Restricted Health Conditions.

(a) Prior to admission of a resident with a restricted health condition, the licensee shall:

(1) Communicate with all other persons who provide care to that resident to ensure consistency of

care for the condition.

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs

complete training provided by a licensed professional sufficient to meet those needs.

RCFE Placement

January 25, 2017

Page 5

(A) Training shall include hands-on instruction in both general procedures and resident-specific

procedures.

(B) Training shall be completed prior to the staff providing services to the resident.

(b) Should the condition of the resident change, all facility staff providing care to that resident shall

complete any additional training required to meet the resident's new needs, as determined by the resident's

physician or a licensed professional designated by the physician.

(c) The licensee shall document any significant occurrences that result in changes in the resident's

physical, mental and/or functional capabilities and immediately report these changes to the resident's

physician and authorized representative.

(d) A resident's right to receive or reject medical care or services, as specified in Section 87468, Personal

Rights, shall not be affected by this section.

(1) If a resident refuses medical services the licensee shall immediately notify the resident's

physician or licensed professional designated by the physician and the resident's authorized

representative, if any, and shall participate in developing a plan for meeting the resident's needs.

87615. Prohibited Health Conditions.

(a) Persons who require health services for or have a health condition including, but not limited to, those

specified below shall not be admitted or retained in a residential care facility for the elderly:

(1) Stage 3 and 4 pressure sores (dermal ulcers).

(2) Gastrostomy care.

(3) Naso-gastric tubes.

(4) Staph infection or other serious infection.

(5) Residents who depend on others to perform all activities of daily living for them as set forth in

Section 87459, Functional Capabilities.

(6) Tracheostomies.

87616. Exceptions for Health Conditions.

(a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception

request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes

that the intent of the law can be met through alternative means.

(b) Written requests shall include, but are not limited to, the following:

(1) Documentation of the resident's current health condition including updated medical reports,

other documentation of the current health, prognosis, and expected duration of condition.

(2) The licensee's plan for ensuring that the resident's health related needs can be met by the

facility.

(3) Plan for minimizing the impact on other residents.

(c) Facilities that have satisfied the requirements of Section 87632, Hospice Care Waiver, are not required

to submit written exception requests under this section for residents or prospective residents with

restricted health conditions under Section 87612 and/or prohibited health conditions under Section 87615

provided those residents have been diagnosed as terminally ill and are receiving hospice services in

accordance with a hospice care plan as required under Section 87633, Hospice Care for Terminally Ill

Residents, and the treatment of such restricted and/or prohibited health conditions is specifically

addressed in the hospice care plan.

87617. Departmental Review of Health Conditions.

(a) Certain health conditions as specified in Sections 87618, Oxygen Administration -Gas and Liquid,

through 87631, Healing Wounds, may require review by Department staff to determine if the resident will

be allowed to remain in the facility. The Department shall inform the licensee that the health condition of

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RCFE Placement

January 25, 2017

Page 6

the resident requires review and shall specify documentation which the licensee shall submit to the

Department.

(1) Documentation shall include, but not be limited to the following:

(A) Physician's assessment(s).

(B) Pre-admission appraisal.

(C) Copies of prescriptions for incidental medical services and/or medical equipment.

(2) The documentation shall be submitted to the Department within 10 days.

(b) If the Department determines that the resident has an allowable health condition, the licensee shall

provide care and supervision to the resident in accordance with the conditions specified in Sections

87618, Oxygen Administration -Gas and Liquid, through 87631, Healing Wounds.

ACTION REQUESTED:

Information only

DR:br

January 25, 2017

TO: Case Management Committee Members.

FROM: Pat Blaisdell, VP Continuum of Care

Debby Rogers, VP Clinical Performance and Transformation

SUBJECT: Current Issues/Old Business

SUMMARY

The CHA Case management committee continues to track several issues that have significant

implications for CHA member organizations.

ACTION REQUESTED

To provide updates and status reports on other areas of interest.

DISCUSSION

End of Life Option Act

The End of Life Option Act, which allows individuals to seek aid in dying from physicians,

under certain circumstances, went into effect in June 2016. Committee member have expressed

an interest in discussing implementation. Attendees are encouraged to share experiences and

practices.

MediCal Managed Care/Coordinated Care Initiative At CHA’s request, Harbage Consulting developed presentation materials and a case manager

“tool-kit” regarding Cal MediConnect policies and procedures, including access to care

coordination, authorization procedures, and other. Based on the questions that they have

received, Harbage has requested some additional input from CHA, and suggestions for next

steps.

CHA continues to work with the Department of Health Care Services (DHCS) and individual

health plans to address several concerns identified by member hospitals regarding care

coordination, care authorizations and access to care for beneficiaries enrolled in managed care,

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Current Issues

January 25, 2016

Page 2

including Cal MediConnect and the coordinated care initiative (CCI), the California dual

demonstration.

Durable Medical Equipment

At CHA’s request, CMS Region IX conducted a webinar for hospital case managers regarding

policies and procedures for ordering and obtaining durable medical equipment, prosthetics,

orthotics and supplies (DMEPOS). The content, which was developed in consultation with

CHA, included coverage policies, documentation, identification of a supplier, and

complaint/problem resolution. The webinar was part of CHA’s ongoing work to address

member concerns regarding delays and other issues encountered when ordering medically

necessary durable medical equipment (DME) since the initiation of the Centers for Medicare &

Medicaid Services (CMS) Competitive Bidding Program.

PACE

Representatives of CalPACE, the state association that supports programs of all-inclusive care

for the elderly (PACE) located in California, have expressed interest in developing policies and

procedures that would facilitate the transition of patients from hospitals to PACE programs.

PACE programs are interested in receiving input from hospital case managers regarding factors

affecting the transition process and how they may be addressed.

Pre-admission screening and resident review (PASRR) CHA is working with the Department of Health Care Services (DHCS) to facilitate the

implementation of new procedures and policies associated with requirements for completion of

the pre-admission screening and resident review (PASRR). The purpose of the PASRR is to

ensure that individuals with mental illness or intellectual disability receive appropriate services.

Completion of PASRR is required for certain individuals prior to admission to a skilled nursing

facility. DHCS personnel have shared with CHA staff a draft form and additional information

regarding the proposed process. CHA has advanced several questions regarding the scope of the

screening form/information gathering and other issues. There are not updates on this issue from

the last meeting of case management committee.

CASE MANAGEMENT COMMITTEE 2017 Meeting Dates

_____________________________________________________________________________

WEDNESDAY, JANUARY 25, 2017

10:00AM – 2:00PM

CHA- Board Room



WEDNESDAY, MARCH 22, 2017

10:00AM – 2:00PM

CHA- Board Room



WEDNESDAY, JUNE 14, 2017

10:00AM – 2:00PM

CHA- Board Room



WEDNESDAY, OCTOBER 4, 2017

10:00AM – 2:00PM

CHA- Board Room



Wednesday, November 15, 2017

10:00am – 11:00am

Conference Call: (800) 882-3610

Pass Code: 4920025#

81

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