Back to Basics: Improving the Quality of Your Case Management Services

1. Back to Basics: Improving the Quality of Your Case Management Services Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc. & George Washington Universitywww.positiveoutcomes.netjulia.hidalgo@positiveoutcomes.net

2. EFFECTIVE ELIGIBILITY DETERMINATION IN THE RYAN WHITE PROGRAM AND OTHER SYSTEMS

3. Why conduct eligibility determination for HIV+ clients? • Adhere to the federal Ryan White HIV/AIDS Treatment Modernization Act of 2006 • Ensure clients receive the optimal benefits that they are legally eligible • Ensure access to health care and medications through enrollment in ADAP, AICP, or other public programs • Through enrollment in commercial insurance, ensure access to a full range of health care benefits not commonly covered by the Ryan White Program • Ensure income maintenance through disability income and other income maintenance programs • Ensure that HIV clinics and other health care providers are compensated for their services

4. Ryan White Program Payer of Last Resort Policies • The Ryan White Program is the payer of last resort (PLR) • Grantees and subgrantees (i.e., contractors) must ensure that clients meet eligibility criteria for Ryan White-funded services • Including ADAP, AICP, and direct services • Grantees and subgrantees must ensure that alternate payment sources are pursued before providing Ryan White-funded services • Grantees must establish and monitor procedures to ensure that their subgrantees verify and document client eligibility

5. Payer of Last Resort Policies • Direct service grantees and subgrantees must document that their clients are screened for and enrolled in eligible programs and their benefits are coordinated after enrollment • Medicare, Medicaid, private health insurance • Other programs include public housing, drug or mental health treatment, or Food Stamps • Income assistance, including disability income and Temporary Assistance to Needy Families (TANF) • Grantees must coordinate with other funders to ensure that Ryan White Program funds are the PLR • Including coordination with the VA • These and other HAB requirements are subject to audit

6. Components of Eligibility Determination • Applicant’s identify • HIV seropositive status, or affected family member (for some services) • Residency • Health insurance enrollment • Income

7. Eligibility Determination: Pieces of the Puzzle • There is a vast array of entitlement and discretionary programs that HIV+ clients may be eligible for today and tomorrow • Eligibility criteria (the short list) • Geographic residency, US citizenship, legal residency status, age, gender, previous financial contributions by client, employment status, type of employer, preexisting medical condition, disability, employability, income, assets, HIV serostatus, CD4 count, annual or lifetime utilization of benefits, criminal convictions

8. Medicaid Eligibility For HIV/AIDS Beneficiaries Adapted from Kaiser Family Foundation HAB presentation

9. SSI and HIV/AIDS • Substantial state variability in the acceptance rates of SSI applications from HIV+ individuals • Initial denial rates tend to be very high in most states • Significant changes are being made to State Medicaid programs due to the Deficit Reduction Act (DRA) • Example: beneficiaries and applicants must document their US citizenship • Disability claims are taking longer than ever to process • Many State and federal entitlement programs have had layoffs or are working with inexperienced staff • New SSI HIV/AIDS disability criteria was published in June 2009 • Adults: http://www.ssa.gov/disability/professionals/bluebook/14.00-Immune-Adult.htm • Children: http://www.ssa.gov/disability/professionals/bluebook/114.00-Immune-Childhood.htm

10. SSI and HIV/AIDS • In Florida, the Division of Disability Determinations (DDD) makes decisions regarding the medical eligibility of Floridians applying for disability benefits under the federal SSDI, SSI, and the state Medically Needy program • DDD is also responsible for redeterminations • Applications for disability benefits are filed at the local Social Security Administration field office when an claimant seeks disability benefits under the Social Security Act, or at a local DCF office of the when benefits are sought for the Medically Needy program • The application is forwarded to DDD for a determination of medical eligibility • The claim is then returned to either SSA or DCF for a final determination of non-medical eligibility and effectuation of any benefits due the claimant What has been your HIV+ clients’ experience applying and enrolling in Medicaid?

11. Medicare Eligibility For HIV/AIDS Beneficiaries • Medicare Part D Enrollment • Implementation was challenging • HIV+ Medicare beneficiaries continue to express challenges in comparing plans • What has been your HIV+ clients’ experience with Medicare Part D? Adapted from Kaiser Family Foundation HAB presentation

12. Pop Quiz • What is the difference between SSI and SSDI? • Can you be enrolled simultaneously in Medicaid and Medicare? • True or false? A client cannot be enrolled in Medicaid and Ryan White-funded programs? • Under what circumstances can a Medicare beneficiary receive Ryan White-funded services?

13. Commercial Insurance • Coverage is primarily through group benefits via employers or association membership • Individual coverage can be purchased through carriers • Benefits vary substantially among carriers • ED must address • Waiting periods for pre-existing medical conditions • Annual or lifetime caps • Service utilization limits for specific services (e.g., number of prescriptions, home health visits) • HIV+ beneficiaries of these plans may receive Ryan White Program benefits during waiting periods or while services caps are exceeded

14. Commercial Insurance • Some eligible HIV+ individuals do not seek insurance or drop their coverage due to • Concern about HIV disclosure and discrimination • Growing premiums, co-payments, and deductibles • Case managers should not encourage enrollment in Ryan White Program-funded programs as a substitute to health insurance available to them • However, assistance may be available through AICP • It is important to counsel clients • To retain or seek coverage during “open season” • Seek improved coverage if they have limited benefits or high premiums, co-payments, or deductibles

15. Pop Quiz • Can you be enrolled simultaneously in commercial insurance and Ryan White-funded programs? • Can a Ryan White-funded program accept commercial insurance? • Under what circumstances can a commercial insurance beneficiary receive Ryan White-funded services?

16. What is HAB’s policy regarding veterans? • In 2004, HAB clarified their policy about providing Ryan White Program-funded services to HIV+ veterans who also are eligible for VA benefits: http://hab.hrsa.gov/law/0401.htm • Ryan White Program providers • Should inquire if a client is a veteran and enrolled in the VA • May not deny services, including medications, to veterans who are otherwise eligible for the Ryan White Program • Should be knowledgeable about VA medical benefits, including medications • Must coordinate health care benefits for veterans • Make HIV+ veterans aware of VA services available, procedures for getting VA care, and help them to navigate HIV care • Even if enrolled in the VA, a veteran does not have to use the VA as their exclusive health care provider

17. What are the eligibility criteria for veterans to receive services from the VA? • Eligibility information is available at: http://www.va.gov/healtheligibility/HECHome.htm • Eligibility for most veterans health care benefits is based on active military service in the Army, Navy, Air Force, Marines, or Coast Guard, and other criteria • VA health care benefits are not just for veterans who served in combat or have a service-connected injury or medical condition • Not all veterans are eligible for VA benefits • In recent years, VA eligibility requirements have become increasingly strict

18. Eligibility for Other Publicly Funded Services • Under the Ryan White Program PLR policy, if a client is eligible for services through other publicly funded services they should be referred to those services before Ryan White Program-funded services should be provided • Examples include • Substance abuse treatment services • Mental health services • Food/pantry services • Transportation • Utilities assistance • What challenges have your HIV+ clients experienced enrolling in these programs?

19. POP QUIZ: TRUE OR FALSE1. Physicians and other clinicians can help HIV+ patients to enroll in Medicaid2. The reception staff at HIV clinics can assist in periodic re-determination of health insurance coverage3. Re-determination should only be done once per year4. I am very familiar with eligibility requirements for Medicaid, Medicare, ADAP, and my state’s Health Insurance Continuation Program

20. Partners in Effective ED

21. Partners In Eligibility Determination • Case managers or other ED staff • Physicians documenting disability • Reception staff • Other payers and other systems • Legal advocacy programs • Clients • Direct service agency managers and HIV program directors

22. Effective Strategies In Working With Clients • Communicate with clients that to continue to operate, your program must have revenue • Avoid the attitude “don’t ask, don’t tell,” giving the clients the impression that there is a free lunch • Providers are often unaware that clients are already enrolled or eligible for care • Concerns about discrimination and stigma are real and may result in lack of complete disclosure • Do not assume that clients can navigate the system, read, or complete forms • Conversely, do not assume that clients cannot navigate the system when some can • ED processes that rely heavily on clients are commonly doomed • Paperwork is not the highest priority when you are trying to survive • Ensure that clients receive the maximum benefit to which they are legally entitled • What other strategies do you use?

23. Role of HIV Program Directors and Case Management Supervisors • Link with HIV clinics to obtain documentation of clients’ HIV serostatus • Case managers working in clinics must document HIV serostatus in your clients’ case management charts • Use standardized forms and train personnel to use them • Ensure forms are linguistically appropriate to the subpopulations served • Address the varied literacy level of clients • Clearly identify expectations to case managers regarding chart documentation • Require tax returns or credit checks to document income, assets, and employment

24. Role of HIV Program Directors and Case Management Supervisors • Some agencies find electronic case management software helpful in ED screening • It is important that the software be updated regularly to reflect new programs or changes in existing programs • Reflect the availability of state and local programs • Review your policies and procedures with your ED staff to determine what is actually being done • Talk to your staff, assess data, and conduct your own audits • Develop continuous quality improvement (CQI) to improve ED • Train and retrain ED staff and test their knowledge periodically • Use trained and experienced supervisors

25. Role of HIV Program Directors and Case Management Supervisors • Systematically assess the ED processes by applying performance standards and auditing charts • Use benchmark data to compare the performance of ED staff • Do not assume that your program’s case managers are “handling it” • Many case managers report that their case loads are too high and that they are not trained to handle ED • Assess if case managers are the most cost-effective personnel model for ED • Identify entitlement and discretionary programs for which there are barriers to enrollment • Document the problem and establish ongoing processes for resolution; an important advocacy role • Communicate with other HIV programs to document system-wide barriers • How do supervisors in your agency monitor ED functions of your HIV case managers?

26. Role of HIV Program Directors and Case Management Supervisors • Routinely monitor changes in entitlement and discretionary programs that impact eligibility and adjust accordingly • Changes to major payers in your community should be rapidly communicated to ED workers • Meet with county DSS staff to become familiar with their processes, get on the list for program announcements, and ask if your staff can participate in training • Do not assume another agency will take care of ED unless that explicit role is assigned to them • Coordinate with community partners if another agency is responsible for ED • Determine how client-level will be transmitted effectively between agencies, with HIPAA requirements addressed for data transfer

27. Role of HIV Program Directors and Case Management Supervisors • Collaborate with other care systems to identify resources and coordinate referrals • Other systems include substance abuse and mental health treatment, affordable housing, pantry/nutrition programs, transportation, etc. • Legal services may be available (through Ryan White-funded programs or referral) to pursue administrative procedures following rejected disability or other claims and to assist clients in employment discrimination cases • Establish processes with SSA to fast track applications and to train disability determination staff regarding HIV disease • Are there other actions your HIV program director or supervisor can do to help you do ED?

28. Strategies For HIV Programs • Receptionists should ask ALL clients at EACH visit for a copy of their health insurance card, including Medicare Part D enrollment card • Any changes should be reported to the case management staff • It is important that receptionists not assume that no change has occurred • At the beginning of each calendar year, it is important to confirm insurance status • Scheduling staff should confirm through the online Medicaid system that the client is newly or still enrolled • Confirm Medicaid enrollment the day before the client’s appointment • What if our agency is not a Medicaid provider? • Copies of new health insurance cards should be made and filed in the client’s chart

29. Effective ED Strategies • Do not front-loaded ED at entry in care • Screen for eligibility on a routine basis (e.g., every six to twelve months) • Use rolling re-determination to normalize required staffing • Intake and re-determination forms should be tailored to screen for the unique set of health and other programs in your community • It is not enough to ask a client if he/she is enrolled but assess eligibility based on the criteria used for relevant programs • Knowing how to complete the paperwork, document claims, and making sure clients follow through are the keys to success • Request the case management charts of new clients moving from other states

30. Effective ED Strategies • Medical providers must communicate with ED staff about eligibility “triggers” • Loss of employment due to disability, inability to be employed due to the side efforts of HAART, inpatient admissions, changes in clinical condition • Do not assume that clients’ disability claims should only be HIV-related, they may have other chronic conditions • Coordinate applications for benefits • Avoid flooding the system with completed forms to “see what sticks” • Do not advise clients to “get a Medicaid rejection letter” so they can access Ryan White Program-funded services • Rather, work with clients to prepare valid, accurate applications for benefits • Partner with legal aid staff to prepare well documented applications and address discrimination issues • What other strategies do you use?

31. Documenting Eligibility for the Ryan White Program and Other Funded Services

32. Health and Case Management Record Basics The chart or record is the core element of a visit or other unit of service • Since eligibility determination services are purchased by the Ryan White Program 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

33. ED 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

34. ED Documentation • Information should be recorded 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

35. Case Conferences

36. Pop Quiz: Who is the Client? Case 1 • Antonio is a 45 year old HIV+ construction worker that recently relocated to Orlando from New York. He and his HIV+ wife have two children ages five and two. His wife recently left him, and he is caring for the children on his own. Antonio has advanced HIV disease, and chronic orthopedic conditions that prevent him from working. He reports having no income, no health insurance, and is worried that he cannot care for his children.

37. Pop Quiz • 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?

38. Pop Quiz: Who is the Client? Case 1 This is what we know from intake: • Antonio is a 45 year old HIV+ construction worker that recently relocated to Orlando from New York. He and his HIV+ wife have two children ages five and two. His wife recently left him to care for the children on his own. Antonio has advanced HIV disease, and chronic orthopedic conditions that prevent him from working. He reports having no income, health insurance, and is worried that he cannot care for his children.

39. Pop Quiz: Who is the Client? Case 2 This is what we know from intake: • Marvin is a 50 year old HIV+ male that lives with his 75 year old mother. He has been HIV+ for seven years, with a declining CD4 count and increasing viral load. He is often is too depressed to go to his HIV clinic visits, take his medications, or care for himself. At intake, Marvin’s mother is unaware that he is HIV+. At the advise of his case manager, Marvin tells his mother that he is HIV+. She is depressed and anxious, as she worries that Marvin may die.

40. Case Conference 4 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. His physician reports that Marvin is showing signs of HIV dementia and wasting.