TARGETED CASE MANAGEMENT (TCM)
TCM is defined as a Medicaid-reimbursable service furnished to assist eligible individuals in gaining access to needed medical, social, educational and other services. TCM includes the following:
Comprehensive assessment at admission and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services.
Development (and periodic revision) of a specific care plan that is based on the information collected through the assessment that:
Specifies goals and actions to address the medical, social, educational, and other services needed by the individual; includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individualís authorized health care decision maker) and others to develop those goals; and identifies a course of action to respond to the assessed needs of the eligible individual.
Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services including:
Activities that help link the individual with medical, social, educational providers, or other programs and services that address identified needs and assist the individual achieve goals specified in the care plan.
Monitoring and follow-up activities:
Activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the eligible individualís needs, and which may be with the individual, family members, services providers, or other entities or individuals and are conducted as frequently as necessary, and include at least one annual monitoring. A minimum of annual monitoring is conducted, and in most cases monitoring will be more frequent (e.g., monthly, quarterly) in order to determine whether the following conditions are met:
Services are being furnished in accordance with the individualís care plan;
Services in the care plan are adequate; and
Changes in the needs or status of the individual are reflected in the care plan.
Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.
Monitoring may be conducted by staff face-to-face or by telephone contact with the individual, by chart review, by case conference, or by collateral contact with family members, service providers, or other entities or individuals.
TCM includes contacts with non-eligible individuals that are directly related to identifying the eligible individualís needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individualís needs.
The target group includes individuals age 18 or older with serious and chronic mental illness as defined by the Department of Mental Health and Addiction Services (DMHAS), in consultation with the Department of Social Services. The target group is inclusive of individuals with substance use disorders and co-occurring mental illness. Providers can bill for TCM services provided to individuals who are receiving them for one of the primary ICD-10 diagnoses on the target group list.
Case management services are available for up to 180 consecutive days of a covered stay in a medical institution. In accordance with federal Medicaid policy, the target group does not include individuals between ages 22 and 64 who are served in Institutions for Mental Disease or individuals who are inmates of public institutions.
The target group includes individuals transitioning to a community setting (e.g. to-from a nursing facility, general hospital, and emergency department but not individuals transitioning to or from an institution for mental disease).
Providers must maintain case records for all individuals receiving case management services. Such records must document: (i) The name of the individual; (ii) The dates of the case management services; (iii) The name of the provider agency and the person providing the case management service; (iv) The nature, content, units of the case management services received and whether goals specified in the care plan have been achieved; (v) Whether the individual has declined services in the care plan; (vi) The need for, and occurrences of, coordination with other case managers; (vii) A timeline for obtaining needed services; (viii) A timeline for reevaluation of the plan.
Content Last Modified on 5/30/2017 10:00:25 AM