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Manage Treatment Plan and Outcomes

Case Management

CMS names this process two ways. The Business Process Template and the framework's business architecture index use the name above; the Business Capability Model (Appendix D) publishes it as Manage Treatment Plans and Outcomes.

Description

The Manage Treatment Plan and Outcomes business process uses federal and state specific criteria and rules to ensure that the providers/contractors chosen and services delivered optimizes member and member population outcomes. It includes activities to track and assess effectiveness of the services, treatment plan, providers/contractors, service planning and coordination, episodes of care, support services, and other relevant factors. It also includes ongoing monitoring, management, and reassessment of services and treatment plans for need, appropriateness, and effectiveness, and monitoring of special member populations (e.g., pregnant women and children, and HIV/intravenous drug users). Health Information Exchange (HIE) monitors a member’s health information.

Business Process Template

Trigger events
Environment-based
  • Periodic review of member’s treatment plan is due.
  • Receive request to review member’s treatment plan.
Interaction-based
  • Receipt from Health Information Exchange (HIE) of a modification in member’s health outcome.
  • Receive treatment plan from Establish Case business process.
Results
  • Member’s treatment plan and outcomes are appropriate for their needs.
  • Send modification (e.g., creates, update, delete) to member’s treatment plan sent to Health Information Exchange (HIE).
  • Member, provider and care coordinators notified of modifications in treatment plan or benefits.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive member’s treatment plan from Establish Case business process.
  • 2. Review of effectiveness of the services, treatment plan, providers/contractors, service planning and coordination, episodes of care, support services, and other relevant factors.
  • 3. Determine if modifications are necessary for effective treatment outcome.
  • 4. Record required modifications to member’s treatment plan.
  • 5. END: Send notification to member, provider and other care coordinators of modification in treatment or benefits.
  • Alternate Path:
  • 1. START: Receive treatment plan from Health Information Exchange (HIE).
  • 2. Review of effectiveness of the services, treatment plan, providers/contractors, service planning and coordination, episodes of care, support services, and other relevant factors.
  • 3. Determine if modifications are necessary for effective treatment outcome.
  • 4. Record required modifications to member’s treatment plan.
  • 5. Send notification to member, provider, and other care coordinators of modification in treatment or benefits.
  • 6. END: Send modification to member’s treatment plan or benefits to Health Information Exchange (HIE).
Predecessor processes
Successor processes
Shared data
  • Member data store including demographic and social information
  • Health Information Exchange (HIE) data store including health information, medically-related social and support services, clinical record, and clinical data
  • Case History data store including action lists, journal notes, reviews, and approvals
Constraints

Agencies do not coordinate amongst each other in order to share information. Potential political and inter-agency conflicts over appropriate use of health care information.

Failures
  • Care Manager is unable to acquire treatment plan information.
Performance measures
  • Timeliness to complete process = within __ days
  • Accuracy with which changes are applied = ___%
  • Consistency of decisions and disposition = ___%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Care Management BPT.pdf, pages 12-14.

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?
  1. LEVEL 1The process consists primarily of manual activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
  3. LEVEL 3SMA automates process to the full extent possible within the state Health Information Exchange (HIE).
  4. LEVEL 4SMA automates process to the full extent possible across the interstate region via the regional Health Information Exchange (HIE).
  5. LEVEL 5SMA fully automates the process nationally to the extent possible via the Nationwide Health Information Network (NwHIN).
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2A mix of HIPAA information standards and state-specific standards are applied.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate state Health Information Exchange (HIE) exchange of clinical information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and regional Health Information Exchange (HIE) exchange of clinical information.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of clinical information via the NwHIN.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA collaborates with other intrastate state Health Information Exchange (HIE) and entities to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA collaborates with other interstate regional Health Information Exchange (HIE) and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA collaborates with the NwHIN agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
  4. 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.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity 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?
  1. 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.
  2. 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.
  3. LEVEL 3Automation of information collection increases the reliability of state Health Information Exchange (HIE)’s internal information. External sources of information use MITA Framework for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
  4. 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 regional Health Information Exchange (HIE). Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
  5. 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?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
  3. LEVEL 3SMA easily obtains and uses information from intrastate state Health Information Exchange (HIE) and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2.
  4. LEVEL 4SMA easily obtains and uses information from interstate regional Health Information Exchange (HIE) and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA easily obtains and uses information via the NwHIN. Accessibility is greater than Level 4.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of its results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards by state Health Information Exchange (HIE) further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for regional Health Information Exchange (HIE) exchange improving cost effectiveness ratio over Level 3.
  5. 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?
  1. 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.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate state Health Information Exchange (HIE) and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional Health Information Exchange (HIE) and entities improving efficiency to 98% or higher.
  5. 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?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate state Health Information Exchange (HIE) and entities improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional Health Information Exchange (HIE) and entities improving accuracy to 98% or higher.
  5. 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?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate state Health Information Exchange (HIE) and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with regional Health Information Exchange (HIE) and entities improving stakeholder satisfaction to 95% or higher.
  5. 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 33-39.

Other Care Management processes

Authorize ReferralAuthorize ServiceAuthorize Treatment PlanEstablish CaseManage Case InformationManage Population Health OutreachManage RegistryPerform Screening and Assessment