CM
Manage Case Information
Case Management
Description
The Manage Case Information business process uses state-specific criteria and rules to ensure appropriate and cost-effective medical, medically-related social and behavioral health services are identified, planned, obtained and monitored for individuals identified as eligible for care management services under such programs as: • Medicaid Waiver program case management • Home and Community-Based Services (HCBS) • Other agency programs • Disease management • Catastrophic cases • Early Periodic Screening, Diagnosis, and Treatment (EPSDT) • Immunizations for children and adults The Establish Case business process creates each individual case and treatment plan. The Manage Case Information business process includes activities to confirm delivery of services and compliance with the plan. It also includes activities such as: • Service planning and coordination. • Facilitation of services (e.g., finding providers, or establishing limits or maximums). • Advocating for the member. • Monitoring and reassessment of services for need and cost effectiveness. - This includes assessing the member’s placement and the services received and taking necessary action to ensure that services and placement are appropriate to meet the member’s needs. The Health Information Exchange (HIE) provides health information and clinical records for member and care coordination with provider, pharmacist, and other agencies.
Business Process Template
Trigger events
Environment-based
- Periodic timetable (e.g. monthly, quarterly) review of a case is due.
- Monitor member’s case activity.
- Receive case modifications (e.g., create, update, or delete).
Interaction-based
- Receive information regarding services delivered/not delivered (including claims information).
- Receive health plan or health benefit modification that may affect a treatment plan.
- Receive information regarding an enrollment modification, including disenrollment.
- Receive information regarding modification in member’s conditions or situation.
Results
- Updated case history with possible revision to the following: o Case history o Needs assessment o Treatment Plan o Associated Providers List o Case file information (e.g., contact dates and times)
- Content of communications sent to providers and members.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive request to review case (review of the member’s status and needs).
- 2. Based on review, take follow-up action, as needed, to: o Identify services delivered, issues impeding delivery of service and/or member’s progress. o Establish appointment with member to review case status. o Contact provider(s) to review member’s progress. o Review services provided (claims payment information). o Close case for non-chronic conditions or change in member’s status.
- 3. Revise treatment plan to: o Add or remove services. o Change nature of plan (e.g. shifting drug regimen, shifting from drug to behavioral). o Reassess needs. o Revise expected results.
- 4. END: Send alert to notify of care management modifications or care coordination updates.
Predecessor processes
Successor processes
- Send Outbound Transaction
- Authorize Treatment Plan
- Manage Applicant and Member Communication
- Manage Provider Communication
- Manage Population Health Outreach
- Manage Registry
- Submit Electronic Attachment
- Manage Data
Shared data
- Member data store including demographics
- Health Information Exchange (HIE) data store including health information, clinical record and clinical data
- Enterprise Master Patient Index (EMPI) for single and complete view of patient information
- Provider data store including provider network information
- Health Benefits data store including programs and services Information
- Case History data store including action lists, journal notes, reviews and approvals
Constraints
States and programs within States use different criteria to manage cases. Diseases included in Disease Management differ from state to state. States define and treat catastrophic cases differently. States will conform to required Affordable Care Act requirements for EPSDT and immunizations case management.
Failures
- Information required to manage case is not available or is inaccurate.
Performance measures
- The State Medicaid Agency (SMA) updates cases within the timeframe specified by state policy.
- Movements towards desired health care outcomes because of improvements in case management practices.
Source: CMS MITA 3.0 Business Process Template, Care Management BPT.pdf, pages 4-7.
Business Capability Model (10 questions)
Each capability question defines five maturity levels, from Level 1 through Level 5.
Business Capability Descriptions
Is the process primarily manual or automatic?
- LEVEL 1The process consists primarily of manual, paper-based activity to accomplish tasks. SMA subjectively determines decisions based on interventions.
- LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
- LEVEL 3SMA automates process to the full extent possible within the intrastate Health Information Exchange (HIE). SMA produces audit trail of case determination 100% of the time.
- LEVEL 4SMA automates process to the full extent possible across the interstate by a regional Health Information Exchange (HIE).
- LEVEL 5SMA automates process to the full extent possible nationally via the Nationwide Health Information Network (NwHIN).
Does State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
- LEVEL 2SMA applies a mix of HIPAA and state-specific standards to monitor compliance thresholds established by state and federal regulations, professional standards, or administrative business rules.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for a state Health Information Exchange (HIE).
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange of information via a regional Health Information Exchange (HIE).
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information via the NwHIN.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks. primarily of manual processes (e.g., telephone contacts, facsimile, letters) to gather and share information between social services agencies, physician offices, and other provider types to coordinate care.
- LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) automatic process documents care plan and tracks cases. SMA permits authorized users to access other information bases and retrieve pertinent information about the patient (i.e., eligibility, claims history).
- LEVEL 3SMA collaborates with other intrastate agencies, and entities and the Regional Health Information Organization (RHIO) standards, and to develop and share reusable business services.
- LEVEL 4SMA collaborates with other regional agencies, and entities, and the RHIO to adopt national standards, share reusable processes including clinical information shared via a regional Health Information Exchange (HIE).
- LEVEL 5SMA collaborates with national agencies, and entities, and the RHIO for national (and international) improvements that maximize automation of routine operations shared across the NwHIN.
Business Capability Quality: Timeliness of Process
How timely is this end-to-end process?
- LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
- LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. The process uses automatic reports for tracking compliance with state and federal guidelines for case management and for the delivery of care, improving timeliness over Level 1.
- LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. All information to manage the case is immediately available from a state Health Information Exchange (HIE). Timeliness exceeds Level 2.
- LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has regional Health Information Exchange (HIE) interoperability, which further improves timeliness over Level 3.
- LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies via the NwHIN. Most processes execute at the point of service. Results are almost immediate.
Business Capability Quality: Data Access and Accuracy
How accurate is the information in the process?
- LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
- LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
- LEVEL 3Automation of information collection increases the reliability of a state’s Health Information Exchange (HIE) internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 99% or higher.
- LEVEL 4Automation of information collection increases the reliability of regional Health Information Exchange (HIE)’s internal and external sources of information. SMA adopts MITA Framework for information exchange by interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
- LEVEL 5SMA adopts MITA Framework for national information exchange via the NwHIN. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information in the process?
- LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
- LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
- LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities from a state Health Information Exchange (HIE) based on MITA Framework and industry standards. Accessibility completes in less than three (3) seconds.
- LEVEL 4SMA obtains information easily and exchanges with regional agencies and entities from a regional Health Information Exchange (HIE). Accessibility completes in less than three (3) seconds.
- LEVEL 5SMA obtains information easily and exchanges with national agencies via the NwHIN. Accessibility completes in less than three (3) seconds.
Business Capability Quality: Cost Effectiveness
What is the cost to perform the process compared to the benefits of the results?
- LEVEL 1High relative cost due to low number of automatic, standardized tasks. The process meets state budget guidelines or established dollar thresholds for case savings.
- LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards within a state Health Information Exchange (HIE). The process demonstrates the Return on Investment projected by SMA further improving cost effectiveness ratio over Level 2.
- LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards with a regional Health Information Exchange (HIE) improving cost effectiveness ratio over Level 3.
- LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange via the NwHIN improving cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process?
- LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate Health Information Exchange (HIE) and entities improving efficiency to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional Health Information Exchange (HIE) and entities improving efficiency to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange via the NwHIN improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process?
- LEVEL 1Manual processes result in greater opportunity for human error. The process meets state and federal expectations for member education, coordination of care between providers, and maintaining the plan of care. SMA decision-making is manual for the process is using established parameters and guidelines and may result in some subjective and inconsistent decisions. Accuracy is low.
- LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate Health Information Exchange (HIE) and entities improving accuracy to 95% or higher.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate regional Health Information Exchange (HIE) and entities improving accuracy to 98% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange via the NwHIN improving accuracy to 98% or higher.
Business Capability Quality: Utility or Value to Stakeholders
Does the business process satisfy stakeholders?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process. SMA has few dedicated resources for improve and few measurements in place (e.g. reliance on complaints, legal mandates for action regarding improving stakeholder satisfaction.)
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate Health Information Exchange (HIE) and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
- LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate regional Health Information Exchange (HIE) and entities improving stakeholder satisfaction to 95% or higher.
- LEVEL 5SMA adopts MITA Framework, industry standards and information exchange via the NwHIN improving stakeholder satisfaction to 98% or higher.
Source: CMS MITA 3.0 Business Capability Model, Care Management BCM.pdf, pages 7-15.