HIV Case Management Care Planning and Chart Documentation

1. HIV Case Management Care Planning and Chart Documentation Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc., Harwood MDwww.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net(443) 203 - 0305

2. Ground Rules • I do not represent HRSA, CMS, or DHMH • Let me know if you do not understand • We can share our feelings at the end of each section • You will be rewarded for staying awake • Shut off your electronic devices • A 15 minute break means 15 minutes!

3. Documenting CARE Act and Other Funded Services

4. Health and Case Management Record Basics The chart or record is the core element of a visit or other unit of service • Since case management services are purchased by the CARE Act or health insurers, requirements for medical records are applicable to case management records • It is a systematically organized record of a client’s total care • Everyone who records progress of care in the record should follow the same note writing format • Policies and procedures dictate its organization and use • Creates a verifiable record of services provided for third party payers and other interested parties (QI, accreditation, etc.) • As such, the record should be easily navigated by an external chart reviewer for audit or quality assessment

5. Health and Case Management Record Basics • The record is the primary instrument for planning care • It forms the basis to bill and pay for services • Documentation in the record can be reviewed by third party payers including the CARE Act, Medicaid, and others • Records are legal documents that assist in protecting the interests of the client, facility, and providers • They are considered to be more reliable than an individual’s memory about events • They can be used in court or for other legal matters • They can protect you and your agency in a law suit

6. Record Documentation • Documentation provides the who, what, when, where, why, and how of client care • Regardless of the complexity of documentation, records must be comprehensive enough to meet regulatory, licensing, accreditation, legal, research, quality assurance, and client care needs and purposes • Record notes must be comprehensive enough to support the design and implementation of the care plan and the nature of case management services provided

7. Minimum Record Processes • Develop and implement a process addressing the use of standard forms including • Responsible parties for form development and revision • Form approval process • Definition of timeframe for periodic review and revisions of forms • Consistent use of forms across sites

8. CMS/AMA General Principles of Record Documentation • An individual record is established for each person receiving care • The client’s name should appear on every page with their unique identifier (client record number) • Documentation of each encounter with should include • Reason for the encounter • Relevant history and assessment findings • Assessment or reassessment information • Care plan • Date and legible identity of the observer • Telephone calls or correspondence made on behalf of a client should be documented in the record (including a copy of email correspondence)

9. CMS/AMA General Principles of Record Documentation • The client’s progress, response to, and changes in care plan should be documented • Referrals and other services provided by case managements should be supported by the documentation in the record • The record should be complete and legible • If copying records for transfer to another agency, remember that permanent markers used to redact information may eventually fade, revealing confidential information

10. Universal Record Standards • All information pertaining to a client is kept in the record and must be readily available any time the facility is open • Multiple sites • Filing systems • Records elsewhere • Medical department, substance abuse treatment, mental health treatment

11. Universal Record Standards • Information should be recorded by the case manager at the time of care • At least on the same day • The longer the delay, the lower the quality of the entry • All staff should use the same set of approved abbreviations and symbols • All entries must be dated, timed, chronological, legible, and signed in non-erasable blue or black ink by the provider with his/her credentials noted after their name • No blank spaces in between entries • Do not use WhiteOut or highlighters • Corrections can only be made with a new entry, then cross out and initial old entry • If it’s not legible, it’s not there; if it’s not there, it wasn’t done

12. Chart Questions for Case Managers • Our case management program is located in a clinic, should we consider consolidating the medical and case management record? When can case managers write notes in the medical chart? • Should case managers read their client’s medical record? Should a community case manager request a copy of their client’s medical record? • Should case management record be filed centrally? • Should case managers take client records with them to visit their clients at home, in the hospital, etc.? • When should automated case management records be downloaded onto a disk or flash drive? • Can a client request a copy of their case management record?

13. Automated HIV Case Management Systems • Several automated HIV case management systems are being used successfully in other communities • These systems do not eliminate totally the need for paper records- why? • Automated systems have significant benefits • Routine reminder systems (upcoming appointments, clients due to re-determination) automated referrals and referral confirmation, ability to share records with multiple case managers or agencies, automated reminders about missing data fields • Automated systems also have limitations • Expense of operation and training, IT compatibility, reduced flexibility regarding the record’s content • One size does not fit all

14. Why set-up record policies and procedures? • Maintaining record policies and procedures is essential to protect your program and clients • Licensing and accrediting bodies, as well as governmental entities, require them • Your policies and procedures dictate how health information will be maintained and protected • Your policies set the basis for your legal record

15. Minimum Record Policy Elements • Confidentiality policies and procedures • Chart organization: sections, forms, and their order in the chart • Including specifications of what constitutes a complete record • Record maintenance, storage, retrieval: access to and archiving, backing up, security, and destruction • Client compliance: informed consent and authorization to release information • Record documentation practices: who, how and when; entry authentication; correcting the record • Sanctions or progressive discipline policy for staff who do not make proper entries into records

16. Set Your Record Audit Policy • Case management agencies should have an audit policy in place • Internal record audits should be performed as part of your program’s quality assurance procedures • Internal review allows problems to be identified and corrected before someone else does it for you • Record internal audit policies should address • Audit content • Auditors • Audit timeframes, breadth, and scope • Levels of review • Audit types • Qualitative or quantitative deficiency analysis • Detailed audit process

17. How can we implement our own internal record audits? • As part of your case management program’s quality assurance procedures, an internal audit should be routinely conducted • The audit should assess • Quality and completeness of documentation • Individual case manager’s performance (as reflected in their documentation) • Adequacy of documentation to substantiate that a publicly funded service was provided • High quality services are being provided • Several audit approaches might be used: peer, supervisors, or external contracted auditors • Can we add information into the chart before an audit? • Can’t we wait for someone else to audit us?

18. Questions And Discussion

19. Case Management Care Plan Development and Implementation

20. Case Management Activity Cycle

21. Effective Scheduling: The First Step to Case Management • Receptionists are commonly your agency’s first person in contact with a new client • Friendly and helpful reception and scheduling staff may make the difference in whether a new client follows through with a referral from a counseling and testing site, MD’s office, or other referring agency • Does the receptionist instruct new clients regarding what information to bring the case management intake appointment? • A script can assist reception staff to be consistent, clear, and complete • Are policies in place to ensure that new clients are rapidly assigned a case manager and given an appointment date? • Who communicates with new clients that do not speak English?

22. Client Intake: Best Practices • Standardized forms are used, based on funders’ requirements and feedback from case managers • Case managers receive training and feedback from record audits regarding completeness • Due to the variable literacy of new HIV+ clients, forms are in Spanish and other languages relevant to the populations being served • Family members should not be used to translate • Detailed information is NOT gathered about topics that case manager’s are not trained to address in the assessment and care plan • Examples: mental health screening

23. Client Intake: Best Practices • Assess the client’s family structure and HIV serostatus • Including spouses, partners, and children • Do not assume that single males who have sex with males do not have children • Adolescents may be independently assessed and served due to their fear of family disclosure • This approach is important in developing a family-centered care plan • Assume that new clients may provide additional detailed information as they begin to know and trust their case manager • Identify urgent issues that must be addressed before a full psychosocial assessment should be conducted • Example: Client needs urgent medical intervention

24. Psychosocial Needs Assessment • The depth of useful information gathered in the psychosocial needs assessment often is commonly associated with: • The skill level of the case manager in conducting interviews and care plan development • The interest of clients in entering case management • The extent to which clients are willing to divulge information • Resources available for referral • Is reflected in the approach used to implement the care plan- ranging from information and referral to intensive social work or disease management Information & Referral Intensive Social Work or Disease Management

25. Client Intake: Common Domains of the Psychosocial Needs Assessment Health HIV history Examples: date of first HIV+ test HIV-related conditions HIV transmission category Sexual and STD risk assessment Source of HIV and other medical care Source of dental care Mental health and addictions assessment and history Activities of daily living Nutritional assessment Hospitalization history Medications and adherence assessment “Health literacy” • Do you assess these domains? • What challenges do you encounter assessing these domains? • Among non-clinical social workers, do you feel prepared to assess these domains?

26. Client Intake: Common Domains of the Psychosocial Needs Assessment Psychosocial Housing assessment Including history of homelessness and housing stability, safety, and affordability “Basic needs” Food, transportation, clothing, household/personal items Spousal/partner violence assessment and history Legal issues and incarceration history Emotional, spiritual, and support system Socioeconomic Income and assets Employment and educational attainment Health insurance coverage Other needs identified by the client Do you assess these domains? What challenges do you encounter assessing these domains?

27. Acuity Scales • Most scales are based on one developed in San Francisco early in the HIV epidemic • The scales tend to be overly complex to use, are subjective, and require a thorough psychosocial and clinical assessment • Acuity levels set at intake are likely to fluctuate throughout the course of case management services but are only measured at periodic reassessment • Clients at intake tend to scale high due to significant unmet need • It is important to reassess acuity once the initial needs of the client are addressed, particularly crises • An example of a simplified acuity scale is included in your materials • What are some of your experiences using an acuity scale?

28. Care Plan Development: Best Practices • The record should document a clear thread of logic identified in the psychosocial assessment and carried into the care plan which • Demonstrates the client’s needs, how needs will be addressed, priorities, who will be responsible for addressing the need, the target date for addressing the need, and the planned outcome • If a need was identified but a service was not arranged, you must document why • Client’s should participate in care planning by reviewing the plan, helping to identify priorities, and identifying tasks that he or she will address • Barriers that may impact the client’s needs from being met should be identified • What are some of your tips for care plan development?

29. Identifying Barriers to Addressing Needs: Examples from Oregon Alcohol and drug use Burned bridges Care giving responsibilities Child care Communication Complex medical regimen Cultural Depression or other mental health problems Difficulty with following through Discrimination Doubts about medical effectiveness Financial Health Inadequate community resources Insurance Lack of documentation Lack of information Lack of social support Lack of a regular schedule Language Mental status changes Side effects of medication Transportation Undisclosed HIV status Works outside of the home Other

30. Client Rights and Responsibilities: Best Practices • In reviewing the Client Rights and Responsibilities Forms with your client, it is important to discuss • The goal of case management is to assist the client to function independently • That to the extent possible, you will work with the client to achieve independence • Why certain services are time limited • Example: Emergency food vouchers • What to do if they are having problems managing activities important to maintaining independence and avoid emergencies • Example: Budgeting income to stretch the whole month

31. Client Rights and Responsibilities Forms: Best Practices • What resources, including consumer workshops, are available to assist them to manage their incomes, their HIV infection, and their medications • Additional tips for working with clients to achieve independence will be addressed in our next workshop

32. Progress Notes: Best Practices • The clear thread of logic identified in the psychosocial assessment and carried into the care plan should be also woven into your progress notes • Legibility is important • If an auditor cannot read your handwriting than the service is not verifiable • Just because you can read your hand writing does not mean others can • Hit a “happy medium” between too much and too little documentation • Each identified need and assigned task should be addressed in the progress notes • Some case managers “SOAP” their notes by identifying problems using Subjective, Objective, Assessment, Plans assignments

33. Case Conferencing: Best Practices • Multidisciplinary case conferences are important in addressing complex clients with multifaceted challenges • Some HIV clinics, for example, routinely schedule case conferences • Conference participants might include • Case manager, MD, other clinician, addictions counselor, mental health practitioner, housing counseling, prevention case management, attorney • The client and/or a family member • Notes should be taken during case conferences to identify the who, what, when, and how for addressing the client’s needs • The notes should be signed by the participants and a copy place in the case management record • Case conferences serve as an educational tool to sensitize the care time about the varied roles, responsibilities, and skills of team members • Frequency of conferencing helps build an effective team

34. Re-determination and Reassessment: Best Practices • It is important not to front-loaded intake and assessment at entry in care • Re-determination for CARE Act eligibility and needs assessment should be on a regular basis • Case management agencies tend to re-determine and reassess their clients every six to 12 months • It is important to identify “triggers” signaling that re-determination and reassessment should be conducted • Loss of employment, inpatient admission, change in clinical condition, non-prescribed drug use, suicidal ideation

35. Case Conference 1 This is what we know from intake: Mark is a 16 year old male of mixed race who recently tested HIV+ at an anonymous CTS. Mark was thrown out of his parent’s house recently due to delinquency and drug use. Mark reports a history of parental sexual abuse. He also reports a history of recreational drug use and mentioned he frequents house parties where he uses Viagra, crystal meth, and assorted club drugs. He may have numerous sexual encounters during the parties. Mark reports that he also frequently uses the internet for dates. Mark lives with Stanley, a 35 year old economist. Mark is dependent upon Stanley for housing, income, and transportation, in exchange for which he has sex with Stanley.

36. Case Conference 2 This is what we know from intake: Maria is a 25 year old female residing with her cousin and the cousin’s family. Maria recently immigrated to the US from Central America. She entered the US on a visitor’s visa. Maria speaks and reads a limited amount of English, does not read Spanish, and completed the ninth grade. She test HIV+ while being treated for an STD. Her CD4 count and viral load indicate she is progressing in her HIV disease, with early signs of HIV-related gynecological disease. She has not been treated for HIV, as she is afraid that her cousin will learn of her HIV serostatus and kick her out of the house. She works at McDonalds full time, using her cousin’s Social Security number.

37. Case Conference 3 This is what we know from intake: Marvin is a 45 year old mechanic. He was diagnosed ten years ago with HIV and has several opportunistic infections and hospital stays. He is on salvage HAART. Marvin reports that he can no longer work due to ill health. Currently, Marvin is enrolled in health insurance. He also reports that it is becoming difficult to maintain his apartment, drive to the store, and prepare his meals. He receives HIV care at Greater Baden. His physician reports that Marvin is showing signs of HIV dementia and wasting.

38. Questions And Discussion