1st Bi-Annual UCare Connect Care Coordination Training 2018

May 9th-Care Systems

May 10th-Recorded WebEx

Agenda

• UCare Connect Dental Survey Results

• Advanced Directives

• SMART Goals

• Care Coordination Updates Monthly Activity Logs HRA’s/Care Plans Other Reminders

UCare Connect SNBC Dental Access Project

Project Goals

Dental Home

Reduce ER use

for Dental

Improve Member Dental

Visit Rate

• Conducted by DHS in January 2017

• Goal: Help gather information about community dental providers’ capacity to accommodate the needs of SNBC members.

Provider Access Survey

• Conducted by DHS in Spring 2017

• 2 Surveys: Dental User and Non-User

• Goal: Gathers SNBC member consumer satisfaction information.

CAHPS Dental Satisfaction

Survey

Care Coordinator Survey

• Conducted by 6 MCOs in March 2018 • Goal: Gather feedback on CC’s own experiences

assisting members with dental care, the barriers members face, and experience with MCO resources.

Project Surveys

Care Coordinator Dental Survey

Survey Response Sample Population

• Total: 229 Minnesota Case Managers 32% were UCare Care Coordinators

• 35%7 County Metro

• 53%Greater MN

• 12%Both

How long does it generally take to obtain a dental appointment for a member in your area?

18.39%

33.16%

24.22%

24.22%

72 additional comments Key points:

Location—Greater MN challenges

Member with established clinic

Complicated care needs Willingness to travel for care

In you best estimation, what percentage of your caseload has an active dental provider they have seen in the last year?

21%

47%

27%

5%

9 additional comments Key points:

Lack of providers accepting new MA members

Members with dentures Care will not be covered by

benefit set Use ER

SNBC members may face barriers when trying to access dental services. Rank these potential barriers in the order of prevalence for members on your caseload?

Lack of realizable transportation

Wait time for appt/ member forgets appt

Dental provider not taking new patients

Benefits do not cover dental work that is

needed

Cannot find a dental provider

Distance to nearest provider is too far

7.27%

7.66%

36.20%

26.32%

17.22%

5.33%

109 additional comments Key points:

Lack of providers overall/open to new patients

MCOs receiving false info about who is accepting new patients

Lack of coverage for common SNBC dental carries

Poor experience/ anxiety

What is the primary reason a member chooses not to accept dental services? Rank in order.

1

2

6

5

7

3

4

Were health plan dental resources helpful in resolving member situations?

21.83%

24.45%

18.78%

10.48%

7.86%

16.59%

75% are using resources regularly

38 additional comments Key points:

Online info is not up-to-date and reliable

Benefit info is easy to find

What dental training topics would be helpful as an SNBC Care Coordinator? Oral health care—how it relates to overall

health of the member How to get appointments—what do

providers need to know ahead of time to better serve member?

Issues for people with dentures Benefit set—covered benefits, resources to

help members pay for dental care, average cost, other options when procedures aren’t covered

Feedback & Questions

• Identifying dental clinics/providers that have excessive waiting lists for appointments.

Contact

• Emily Eckhoff, UCare Quality Improvement, eeckhoff@ucare.org

Advanced Directives

Why Are Advance Directives Needed?

• Population is aging.• People are seeking health care alone.• Health crises are unpredictable.• Not appropriate to educate on advance

directives in midst of crisis.• Eases burden for family members/providers.• Reduces fear and worry about health care

decisions.• Communicates your wishes when you are not

able to.

Defining Advance Directives• Legal documents that allow patients to put

healthcare wishes in writing, or to appoint someone they trust to make decisions for them, if they become incapacitated.

• Two types – Living will. Durable power of attorney for healthcare.

• In Minnesota, an Advance Directive is called a Health Care Directive. Combines living will (medical instructions) and

durable power of attorney for health care (someone to act as your agent).

Why Don’t People Have Advance Directives

• Only 18-32% complete the form. Low health literacy rates. Language barriers. Healthy people don’t see the need. Discomfort/superstition with discussion. Just don’t get around to it.

History

• Advance Directives created in response to increasing medical technology.

• 80% of deaths occur in health care facilities.

• Developed to help avoid suffering and costs associated with unwanted treatment.

• Living will proposed in 1969 – provided directives about course of treatment.

• Durable power of attorney added next.

• Wishes and values added later.

History

• 1998 – Minnesota introduced the Health Care Directive tool to help members put wishes into writing.

• Combines living will (1989) and Durable Power of Attorney for Health Care (1993).

• Makes it easier to complete an advance directive.

Did You Know?

• It is just as important for individual who wants to initiate or continue treatment to leave written instructions, as it is for those who have other preferences.

• A health care directive does not require an attorney to complete.

• Once written, a health care directive can be changed or revoked as long as you have the capacity to do so.

What’s in a Health Care Directive?

• Many choices, including: Personal info- name, address, etc. Agent duties – describes them. Agent notes- choose how agent can act, Act alone, together, primary agent,

secondary, etc. Powers of agent- extended or limited. You don’t need to answer every

question.

What’s in a Health Care Directive?

Health care instructions To describe views, beliefs, care preferences,

organ donation. May add your own instructions.

Signatures and dates Notary public or witness signatures.

Records Master list of who has copies. Review and updates.

Required Elements of Health Care Directives

• Must be in writing.• Must be dated.• Must state person’s name.• Must be executed by a person with capacity to do so. • Must be signed by you or someone authorized to sign

for you, when you can understand and communicate your health care wishes.

• Must be verified by a notary or two witnesses.• Must include either health instructions OR a health

care power of attorney, or both.

What to Do with a Health Care Directive

Inform others that it exists.• Inform others of the content, who the

decision makers are, etc.• Give others a copy, especially health care

providers, keep record of who has copies.• Review and update as health care needs

change.• Keep in a safe place, where easily found, not

in safe deposit box.• Copies of the form are valid.

What to Do with a Health Care Directive

Review and update it when there are changes in:• Health status.• State of residence.

An advance directive from another state must meet requirements of each state.

Requests for assisted suicide will not be followed- regardless of state.

• The availability of individuals named as health care agent or alternative agents.

How Long Does It Last?

Until you change or cancel it.

• You can change it by.. Writing a statement saying you want to

cancel it. Destroying it. Telling at least two people you want to

cancel it. Writing a new health care directive.

Advance Directives Will Not Be Honored

When..• The request for treatment is outside of

reasonable medical practice.

• The request is for assisted suicide, euthanasia, mercy killing.

Did You Know?

• It is illegal for health care providers to require patients to complete an advance directive.

• Health care providers are required to tell patients about advance directive laws in Minnesota and note whether or not the patient has one.

• Laws regarding advance directives are not the same in all fifty states in the U.S.

POLST• Provider Orders for Life Sustaining Treatment (POLST)

Is a portable medical order› Is one part of advance care planning, does NOT

replace health care directive.› Identifies what types of treatment a pt. wishes to

receive at end of life or in medical emergency.› Helps convey those wishes to emergency services and

other medical providers.› Used and recognized by hospitals, LTC facilities,

medical professionals, and EMS throughout MN.› Must be signed by a licensed provider to be valid.› Standardized form in MN.› EMS can only follow signed medical orders, thus they

can follow a POLST but not a health care directive.

Care Coordinator’s Role

• Review member record for advance directive information.

• Ask member if they have an advance directive If yes, document the discussion, what

they have, etc. If no, ask if they want to discuss.

Care Coordinator’s Role

• If member wishes to discuss advance directive: Describe advance directive. Ask if they want help completing one- locate

forms, etc. Give ideas or suggestions for talking with

family, etc. Support their ideas or wishes. Follow up on any planned discussion. Give resources for advance directives.

Care Coordinator’s Role

• If member does NOT wish to discuss advance directive: Document that the member does not

want to discuss. Assure members that they will still have

coverage if they choose to have an advance directive, or not.

• Address advance directives annually with all members, and document.

Care Coordinator’s Role

• May assist member in filling out advance directive.

• May not act as witness or authorized agent.

Cultural Considerations

• Approach carefully.

• Respect cultural beliefs about death and dying.

• Do not require member to discuss.

• Document if member does not want to discuss.

• Act as a resource when possible.

Additional Resources

• UCare product overviews on Care Manager’s tab on UCare website. Click on Questions and Answers about

Health Care Directives. Senior Linkage Line.

For More Information

• The Minnesota Health Care Directive: Available in English and Large Print Minnesota Health Care Directive

Planning Toolkit can be printed online at: http://z.umn.edu/mnhcdirective/.

For More Information

• Five Wishes- U.S. Advance Directive Created by Aging with Dignity. Document available in other languages. Discusses individual’s personal,

emotional and spiritual needs as well as their medical wishes.

Available online at http://www.agingwithdignity.org/fivewishes.

Questions?

• Direct questions to: clinicalliaison@ucare.org

• 612-294-5045

SMART Goals

SMART Goals

• Specific – Specifically define the goal for the member using action verbs–what member will do or maintain, and how.

• Measurable – Identify how the member’s success will be measured – how will we know if they met the goals or not?

• Attainable – Make sure the goal is realistic and possible for the member to reach.

• Relevant – The goal should be relevant to the member and reflect member wants and/or needs.

• Time Bound – Establish and STATE a realistic time frame for achieving the goal.

Member Centric Language

• Continue to write goals in first person language “I will…” “My needs…”

• It is important to balance the need for member centered language and SMART goals as both are required components to goal writing

Goal - IADLs/ADLsGoal Category Member Goal Intervention

IADLs/ADLs I will become more independent in walking

Goal - IADLs/ADLsGoal Category Member Goal Intervention

IADLs/ADLs (A/R) I will become

more independent in

walking as

demonstrated by my

(S) (M) ability to walk

with my cane or

walker within the next

3-6 months. (T/A)

I will continue to work

with Physical Therapy 2

days a week to strengthen

my legs and increase my

ability to ambulate

safely.

Goal - Pain Management

Pain Management I will not have pain. Take measures to

control pain.

Goal Category Member Goal Intervention

Goal- Pain Management

Goal Category Member Goal Interventions

Pain

Management

My pain will be (A/R)

controlled as evidenced by

my report, (T) at my next

assessment, of (S/M) a

pain rating of less than ##,

on the 0-10 pain scale

rating.

I will schedule a clinic

appointment to discuss

pain management.

(Is this Time Bound?)

(How could it be

improved?)

Goal – Falls RiskGoal Category Member Goal Intervention

Fall Risk I will reduce my falls risk by

(S/R/A ) using my walker) each

time (T/M) I ambulate greater

than (M) ## feet and report

(M) no falls in a (T) 6 month

time span.

I will utilize adaptive equipment

consistently and notify CM or

Primary Care Provider if service or

equipment not meeting needs.

I will accept services in my home

(homemaking, PT/OT home safety

eval, lifeline) to secure my safety.

My Care Manager reviewed

environmental concerns r/t falls risk

with me (i.e. scatter rugs, keeping

walkways clear, etc.)

My Care Manager will order a falls

prevention kit.

Goals and OutcomesGoal

Category

Goal Interventions Outcomes

Falls Risk I will (R/A )reduce my falls

risk by (S)using my walker

(T) (M) each time I

ambulate greater than (M)

## feet and report (M) no

falls in a (T) 6 month time

span.

I will utilize adaptive

equipment consistently and

notify CM or Primary Care

Provider if service or

equipment not meeting

needs.

I will accept services in my

home (homemaking, PT/OT

home safety eval, lifeline) to

secure my safety.

My Care Manager reviewed

environmental concerns r/t

falls risk with me (i.e. scatter

rugs, keeping walkways clear,

etc.)

My Care Manager will order a

falls prevention kit.

At 6 month check-in, I

have used walker at

least daily for most

walking activities. I

have had no falls in last

6 months.

I am currently receiving

homemaking services,

which help so I am not

on my feet all day.

I have a falls prevention

kit and use the tub grips

in my tub.

Member Goals

Intervention Target Date

Monitoring Progress/Goal Revision Date

Date GoalAchieved/Not Achieved (Month/Year)

Get a showerbench.

Care coordinator will contact DurableMedical Equipment supplier to obtain shower bench.

1/8/18 Bench was obtained

1/8/18

49

What Not to Do- Intervention as a Goal

Member Goals

Intervention Target Date

Monitoring Progress/Goal Revision Date

Date GoalAchieved/Not Achieved (Month/Year)

I will remain free of falls while showering(S, M, A, R) for next six months. (T)

-- CC will order shower bench from DME supplier--Member will shower while homemaker is present for safety--Member will complete strengthening exercises

12/2018 3/13/2018-Shower bench obtained. Member is utilizing when taking a shower. Member is showering when homemaker is present. Exercises not started.

50

Example – Corrected Version

Put Goals to the SMART Test

• Review goals at each assessment/review.

• Do they fit the SMART format?

• Make changes as needed.

• Outcomes should answer the question –was the goal met? What was the outcome of the specific, measureable goal? Was it met or not?

Questions?

Care Coordination Updates

Monthly Activity Logs

• Logging Initial Assessments (ConnectExpansion and Connect + Medicare).

• Logging Annual Reassessments (all Connect products).

• Communicating with UCare regarding members being returned to UCare (all Connect products).

Log and Tip Sheet

• Located on UCare website (here) .

• Only report UCare Connect members/don’t combine products.

• Agency should submit only one combined log.

• Submit to UCare by 20th of following month.

• Save in required format (delegate/month/year).

• Do not modify spreadsheet formatting.

• Don’t forget UCare ID# and not PMI#.

• Do not log transfers between delegates.

Logging Initial Assessments

• Log Initial Assessments for ConnectExpansion and Connect+ Medicare products.

• Initial Assessments must be completed w/in 30 calendar days of enrollment date. Initial, ICCD, Unable to Reach, Refusal.

• Log as assessment or refusal/UTR.

• Submit log by 20th of following month.

Logging Annual Reassessments

• Log annual reassessments for all Connect products – conduct for members on current enrollment roster.

• Complete annual reassessments within 365 days of previous assessment.

• Log as Reassessment, Unable to Reach, or Refusal.

• Could be any HS code type.

Returning Members to UCare Via Monthly Activity Log

• Use log to return members back to UCare when: Member refuses ongoing case coordination services

after assessment, or CC no longer wanted. Unable to reach member for care coordination after

attempts (per requirement grids). Goals met – no longer needs CC. Member refuses annual reassessment, thus refuses

ongoing care coordination. Member becomes a long term resident in SNF. Member is on a community waiver. Do NOT use a Change Fax Form to return members to

UCare – as of 1/1/18.

Members Returned to UCare

Initial and annual assessment HS code types • LU- on waiver, institutionalized• AN – assessed, not interested in CC• NR – unable to reach• NI- not interested in assessment• LM- assessed and not in need of in CC

These members will be returned to UCare and will not be on next month’s enrollment roster.

Care Plans/HRA’s

Completeness of Assessments and Care Plans

• All assessments and care plans should be fully complete.

• If the section does not apply, use N/A.

• All sections should be addressed.

Overdue Assessments

• 117 overdue 1+ months in March

• 76 overdue 1+ months in April Complete reassessments on or before 365th

day. If not able to do, ALWAYS complete MMIS

entry as UTR or Refusal on or before 30/365 days.

• Ideas/discussion for improving UTR/refusals? What are you seeing for reasons for refusals?

Questions?

Submit Logs to:

connectintake@ucare.org by 20th of following month.

Submit questions to: clinicalliaison@ucare.org

Reminders

Care Navigators• All UCare members have a Care Navigator- is a DHS

requirement. Care Navigator – all members

› Is main point of contact unless they are assigned a Care Coordinator

Care Coordinator – some members have in addition to a Care Navigator› Is main point of contact while in care coordination.

Enrollment Roster Reconciliation• Use New and Changes tabs to identify new/changed members.

• Reconcile enrollment roster every month. Know who is on your roster. Reconciliation of members will help reduce enrollment and

payment issues. If discrepancy, contact connectintake@ucare.org Everyone on roster should be receiving care coordination.

Ensure that members you work with are assigned to you for care coordination.

• Payment will ONLY be made for members who are showing on your care coordination enrollment rosters.

• Follow member change process for transfers.

• UCare Webex is available for Enrollment Roster training.

Member’s coverage via MN-ITS

Care Coordinators should be reviewing MN-ITS to:• Ensure the member is assigned to UCare.• Ensure there was no break in coverage when

member is shows as “new” on the care coordination enrollment rosters and were previously assigned. If a member has a break in coverage they

should be treated as a “new” member. If a member does not have a break in coverage

you would want to document this and continue care coordination as usual.

Interdisciplinary Care Team

• Who needs to be included? At minimum, the member, PCP, Care

Coordinator. Any providers who regularly see the member

need to be included› Psych or CD providers.› Therapists- PT, psych, etc.› Regularly can mean once/twice a year or

more.

• We will look for this on audit

Members in 90 day grace period

• UCare Connect members who are in their 90 day grace period Care Coordinators should: Conduct assessment if it is due, no MMIS

entry.› If the member is reinstated within the

90 days enter the assessment in MMIS.

Check to see if member reinstated each month.

UCare Secure Email Site

• UCare cannot open 3rd party secure emails.

• When sending member PHI to UCare Care Coordinators must send it via UCare’s Secure email site: https://web1.zixmail.net/s/e?b=ucare_minnesota&

• If you do not have an account you will need to register.

UCare Website

• UCare will have a new website. Offer’s a fresh look and feel. All your tools/forms will still be there.

• Please take some time to familiarize your self and should you have any questions please reach out.

Care Coordination Questions

We want to be a great resource to you! If you have questions, please include as much detail as possible with your question(s); e.g.:

Member name and ID number. Product they are on. Date of birth. Details about the situation. Your name, phone#, and email address.

This information will allow us to research the situation and provide you with an accurate and prompt response.

Care Coordination Questions cont.

• Round with your team and supervisor prior to sending an email.

• If you still have questions after checking with team and supervisor: send one email outlining the question. share the response with your team after in

order to share the knowledge.

Clinical Liaison Contact

• Ceil Boesche and Bobbi Jo Glood clinicalliaison@ucare.org 612-294-5045

Questions?