Case Work Notes - Maine

Case Work Notes A General Overview of Effective Case Work Documentation for Adult Protective and Developmental Services Case Managers (State and Community) 10/24/2016 1 What is a Note? A note: Documents and reports on meeting the Participants needs and desires.

Documents events in the Participants life. Documents actions of Case Manager taken on behalf of Participant. Is a legal document. 2 What Should I Write a Note About? All meetings and follow-up activities related to those meetings. Ongoing documentation on problematic or unresolved issues and follow-up. A plan to address needs that are identified but lack a resource to get the need met. Any life-altering events, including changes in family or marital status, housing situation or arrangements, employment status, etc. All actions undertaken by the Case Manager or other members of the team related to the Participants services.

Medical/Dental updates and changes. Current Participant Status: Physical appearance (appropriate clothes, good hygiene), mental status, health, safety, and wellbeing. 3 What Information Should NOT be in a Note? The name of the referent of a Reportable Event. Information regarding other Participants receiving services. Information compiled and correspondence with legal counsel in reasonable anticipation of a civil action or proceeding between the client and agency providing services 4

Why are Notes Important? Documents progress towards meeting Participant's needs and desires. Notes are legal documents. Ensures continuity of service for Participant. Improves

accountability between the Case Manager and Participant. Gives the Case Manager credit for the quality of work completed. Allows oversight of the services being performed. 5

What Makes a Good Note? Clear, purposeful, and links to the plan of meeting Participant needs and desires. Free of grammatical and spelling errors. Must be factual and observable. Only includes commonly used acronyms or abbreviations. Not only makes sense to the author, but also to any neutral party. Assumes that the reader is not familiar with the case. Covers a specific contact, are not summaries that cover long periods of time. A note must only cover a less than 24 hour period. 6 What Should be Included in a Note?

Date of Contact Type of Contact Observation(s) Action(s) towards meeting needs and desires of Participant. Follow-Up Facts and verified

information Objective statements Relevant Information Signature (Electronic is valid) Click Here for MaineCare Policy (Section 13

Case Management only). Click here for Adult Protective procedure. 7 Title of the Note (EIS Only) The Title of the Note must be a clear indication of what is being documented within the note. If there is an emergency or crisis after hours, on the weekend, or during a vacation, other people not as familiar with the case will review the notes and

look for relevant and pertinent information to help the Participant. A poorly titled note can result in valuable information being over looked or take up time during an emergency situation. 8 Title of the Note (EIS Only) 9 Date of Contact Case notes need to document the date of the

contact. EIS and MAPSIS usually prompt you for this, but its up to you to enter it correctly 10 Date of Contact - EIS 11 Date of Contact - MAPSIS 12 Type of Contact

EIS and MAPSIS give options for what type of contact a note can cover, though the Case Manager must document the place of the contact and the person/people contacted. Full names should be used, clear relationship to the Participant identified in each note, and their role in the Participants life. If the person is a provider their service and the agency should be identified.

13 Type of Contact - EIS 14 Type of Contact - MAPSIS 15 Observation(s) Issues regarding the

Participants quality of life, satisfaction with services, current life situations, any and all health and safety issues. Personal opinions, judgments or subjective perceptions must not be included in the case note. 16 Observation(s) EIS

Terrence was appropriately dressed for the weather, as evidenced by wearing pants and a long-sleeve shirt during this cool day. 17 Observation(s) MAPSIS The home was relatively clean, as evidenced by a lack of clutter on surfaces and no odor

18 Action(s) Actions that have taken place or take place during the contact. What happened as a result of the contact with the Participant/provider/family member, etc. Actions should have a clear link to the Plan or document progress towards meeting needs and desires of Participants. 19 Action(s) - EIS CM inquired about

Terrences day, and Terrence explained that his feet hurt.. 20 Action(s) - MAPSIS CM inquired about how Gary has been since he moved into his new apartment. This question made Gary upset as he began to cite his concerns about the neighbors upstairs

21 Follow-Up The follow-up includes the actions which need to take place. What needs to happen and who will do it. 22 Follow-Up - EIS CM will follow up by contacting Terrences Guardian, Albert, and determine if another pair of shoes are available or can be purchased.

23 Follow-Up - MAPSIS CM will follow up by contacting Gary within a week and determining what further actions need to be taken, if any, regarding this matter. 24

Signature All notes require the signature of the worker who entered it. EIS and MAPSIS document who entered each note. It is up to the Case Manager to make sure that the name listed is correct and that the correct username is being used. 25 Signature - EIS 26

Signature - MAPSIS 27 Specific Note Examples Now that we have covered how a typical note is written and documented, we will now cover specific examples of what makes a note incorrect or correct. 28 Facts Notes should include facts and verified

information. Do not write assumptions or hearsay. 29 Example of Assumption (Incorrect) CM assumes that Bobby just doesnt want to provide Terrence with transportation 30

Example of Verifying Information and Writing Facts (Correct) Bobby notified CM that Terrence is currently in Bobby notified CM that the hospital to being Terrence is due

currently in involveddue in atocar the hospital being accident. involved in a car accident. 31 Objective

Notes should be objective Not subjective 32 Subjective Example (Incorrect) The place was disgusting and this Case manager cannot understand how anyone can live in such filth

33 Objective Example (Correct) The home was cluttered with magazines, newspapers, and trash bags. A strong odor was also present. 34 E-Mails

E-mail contacts can be summarized in a note. The entire e-mail should not be pasted as a case note. 35 E-mail Example (Incorrect) 36 E-mail Example (Correct) 37

Acronyms and Abbreviations Acronyms and abbreviations are acceptable, so long as they are defined before they are used in each note. 38 Acronyms and Abbreviations (Incorrect) CM recd PC from SMS PSSPC re:from cs

CM recd recent inv.re:CM SMS PSS cs attempted to return recent inv. CM call, there was NA.

attempted to return call, there was NA. 39 Acronyms and Abbreviations (Correct) Case Manager (CM) received phone call from Southern Maine General Personal Support Specialist regarding Garys recent Adult Protective investigation. CM attempted to return the call

but there was no answer. 40 Remember! Notes must be entered within the applicable timeframes: State DS and APS Case Worker Policy: Within 10 business days of contact, except as follows: O Public Guardianship/Conservatorship Appointment: Immediately O Public Guardianship/Conservatorship Temporary Appointment: Immediately O Public Ward Medical Authorization: Within 24 hours of the authorization. O

Crisis Services: Within 24 hours of services being provided. Adult Community Case Manager Guideline: OADS suggests at least within 10 business days of contact. OADS best practice is to enter a note as soon as possible after the contact. Notes are public record, can be used in court, and are available to Participants and guardians. What is written in a note is part of a Participants legal record. 41 Questions? Wanda Lindsay, LSW

[email protected] Developmental Services Supervisor Brian Day, LSW [email protected] Policy and Compliance Specialist 42 Earn The Certificate You may earn a certificate by completing the Knowledge Check: https://www.surveymonkey.com/r/OADSnotes

43 STOP The remainder of this PowerPoint speaks to the Billing Requirements of MaineCare Section 13 Targeted Case Management. 44 Targeted Case Management DS Case Management

services is covered under MaineCare Section 13 policy, specifically Section 13.02. Case Managers may not bill for writing the note itself, only for completing the tasks the billable note documents. For a quarter-hour unit, anything less than 7.5 minutes is not billable. As the majority of DS Case

Management providers utilize EIS General Notes as their source of billing, we will define the different contact types and then identify where the various contact types fall within MaineCare Policy. 45 Contact Types in EIS /Guardian

46 New Contact Types PCP Team Meeting: Documents the annual team meeting, or a monthly, quarterly or semi-annual review meeting of a Person Centered Plan (PCP). PCP Revision: Documents when a PCP is being revised due to a change in services. PCP Coordination: Documents all tasks associated with preparing for the annual PCP meeting, such as contacting the Participant, family, providers, and writing the plan itself. Assessment Completion/Revision: Documents all other Case Manager completed EIS assessments aside from the PCP, such as the DS Supports and Services (V7)/90 Day Review, Comprehensive/Support Waiver (BMS 99), Severely Intrusive and

Safety Plans, Individual Support Team (IST) Plans, etc. 47 Participant Contact Types Telephone Contact with Client: Documents a conversation between the Case Manager and the participant. Office Visit (Face to Face): Documents a face to face visit between the Case Manager and the participant in an office setting. Program Visit (Face to Face): Documents a face to face visit between the Case Manager and the participant while the participant is attending a day program. Home Visit (Face to Face): Documents a face to face visit between the Case Manager and the participant while at the participants home. Employment Visit (Face to Face): Documents a face to face visit between the Case Manager and the participant while the participant is working.

Other Location (Face to Face): Documents a face to face visit between the Case Manager and the participant at any other location that is not covered by another contact type (such as a School or Hospital). 48 Collateral Contact Types Collateral Contact with Family/Guardian: Documentation of contact with a participants family member that pertains to the participant. Collateral Contact with Provider: Documentation of contact with a participants provider that pertains to the participant (typically a waiver provider, such as Community Supports, Home Supports, etc.) Collateral Contact with Medical/Dental Provider: Documentation of a contact with a participants Medical or Dental Provider that pertains to the participant. Collateral Contact with Crisis Service: Documentation of a contact with a Crisis

Worker that pertains to the participant. Collateral Contact with Other: Documentation of a contact with any other person that is not documented in the other collateral contact types and pertains to the participant. 49 Other Contact Types Law Enforcement Contact: Documentation with Law Enforcement Personnel that pertains to the participant. In-Office Meeting/Discussion: A meeting or discussion within an office that is pertaining to the participant (such as supervisory consultation regarding a specific participant, Social Security personnel consultation regarding a specific participant,

etc.) Section 13 Policy Writer: Regular conversations that would occur during supervision are not MaineCare reimbursable. If a supervisor is called in to consult on the development of the care plan, that time can be reimbursable. Documents/Communication Sent/Received: The sending or receiving of documents or other forms of communication that pertain to the participant. 50 MaineCare Benefits Manual, Section 13.02 Covered Services A. Comprehensive Assessment and Periodic Re-assessment of an eligible member to determine service needs, including

those activities that focus on needs identification, to determine the need for any medical, educational, social or other services. The comprehensive assessment and re-assessment must be conducted through face-to-face contact with the member and, where appropriate, consultation with other providers and with the member's family. A comprehensive assessment must be completed within the first thirty (30) days of initiation of services, and reassessment must occur as change in the members needs warrants or at a minimum on an annual basis. These activities include but are not limited to the following: 1.Taking client history; 2.Identifying the needs of the individual and completing related documentation; and 3.Gathering information from other sources (family

members, medical providers, social workers, and educators) if necessary, to form a complete assessment. EIS Contact Types PCP Team Meeting PCP Revision PCP Coordination Assessment Completion/Revision 51 MaineCare Benefits Manual,

Section 13.02 Covered Services B. Development and Periodic Revision of the Individual Plan of Care is based on information collected through a comprehensive assessment or re-assessment that: 1.Specifies the goals and actions to address the medical, social, educational, and other services needed by the eligible individual. Because the assessment of the members needs must be comprehensive, the individual plan of care must also be comprehensive to address all identified needs. Re-evaluation of the individual plan of care must occur as a change in the members needs occurs or at a minimum every ninety (90) days. A member may decline to receive services that have been identified as needs in the individual care plan. If the member declines services listed in the individual care plan, this must be documented in the individuals case record. This 90 day re-evaluation may be completed by the comprehensive case manager.

2.Develops and periodically revises the Individual Care Plan and to the extent possible: a. Ensures the active participation of the member and as appropriate, the member's parent(s) or legal guardian; b. Works with the member (and others as appropriate) to develop goals; and c. Identifies a course of action to respond to the members assessed needs. For a child, the plan of care must be developed with a Child and Family Team. EIS Contact Types

PCP Team Meeting PCP Revision PCP Coordination Assessment Completion/Revision 52 MaineCare Benefits Manual, Section 13.02 Covered Services C. Referral and Related Activities that help an eligible member obtain needed services. As part of the coordination function, the comprehensive case manager must avoid the

duplication of services. The case management referral activity is completed once the referral and linkage has been made. (Referral and related activities do not include providing transportation to the service to which the member is referred, escorting the individual to the service, or providing child care so that an individual may access the service.) These activities are for the purpose of linking the member with medical, social, educational providers or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan. These activities include: 1.Making referrals to providers for needed services, including documentation, and 2.Scheduling appointments for the member.

EIS Contact Types Documents/ Communication Sent/ Received Collateral Contact with Family/Guardian

Collateral Contact with Provider Collateral Contact with Medical/Dental Provider Collateral Contact with Crisis Service Collateral Contact with Other In Office Meeting/ Discussion 53 MaineCare Benefits Manual, Section 13.02 Covered Services

D. Monitoring and Follow-Up Activities that include activities and contacts that are necessary to ensure that the individual care plan is effectively implemented and adequately addresses the needs of the eligible member. This includes contact with the member as needed to monitor the care plan objectives and, if appropriate, periodic contact with the member's family, providers, or other entities. Monitoring may involve either face-to-face or telephone contact. These activities may be conducted as frequently as necessary, but not less than annually, to help determine whether: 1.Services are being furnished in accordance with the individual care plan; 2.Services in the care plan are adequate to address the needs of the member; and

3.Needs or status of the member has changed which requires necessary adjustments in the care plan and service arrangements with providers or service termination. EIS Contact Types

PCP Coordination Telephone Contact with Client

Office Visit (Face to Face) Program Visit (Face to Face) Home Visit (Face to Face) Employment Visit (Face to Face) Other Location (Face to Face) Collateral Contact with Family/Guardian Collateral Contact with Provider Collateral Contact with Medical/Dental Provider Collateral Contact with Crisis Service Collateral Contact with Other In Office Meeting/ Discussion Collateral Contact with Provider Collateral Contact with Medical/Dental

Provider Collateral Contact with Crisis Service Collateral Contact with Other In Office Meeting/ Discussion Law Enforcement Contact 54 Questions About Billing? Contact the MaineCare Provider Relations Specialist for Section 13: http://www.maine.gov/dhhs/oms/contacts.shtml 55

Thematic Note Multiple contact types can now be selected within one note. As an example, if a home visit is completed with both the participant and their parent then 2 contact types could be selected: Home Visit (face-to-face) and Collateral Contact with Family/Guardian. This also allows for the completion of a thematic note. If multiple contacts are made regarding the same theme then one note can be made to cover all of the contacts as opposed to creating separate notes for each separate contact. Even if a thematic note takes place over hours of time, only the time spent that was billable can be claimed as billable time. No note may cover more than a 24 hour period. 56

Thematic Note Example Case Manager (CM) received a phone call from Terry regarding his dissatisfaction with community supports. CM contacted Community Support supervisor CM coordinated a meeting /Guardian 57 Writing Skills

Maine Department of Health and Human Services Staff Education and Training Unit (SETU) offers regularly scheduled trainings pertaining to writing skills. Visit www.maine.gov/dhhs/setu/ to see when trainings are available in your area. 58 Questions? Wanda Lindsay, LSW [email protected] Developmental Services Supervisor Brian Day, LSW

[email protected] Policy and Compliance Specialist 59 Earn The Certificate You may earn a certificate by completing the Knowledge Check: https://www.surveymonkey.com/r/OADSnotes 60

Recently Viewed Presentations

  • The Great Migration

    The Great Migration

    Oscar Stanton De Priest. First African American elected to Congress "I've been elected to congress the same as any other member. I'm going to have the rights of every other congressman - no more and no less - if it's...
  • Looking Out/Looking In Chapter 9

    Looking Out/Looking In Chapter 9

    Looking Out/Looking In Eleventh Edition Chapter Nine: Improving Communication Climates Ronald B. Adler, Russell F. Proctor II, and Neil Towne Improving Communication Climates Communication Climate: Confirming Communication Recognition Acknowledgement Endorsement Communication Climate: Disconfirming Communication Verbal Abuse Complaining Impervious Responses Interrupting...
  • Heredity & Reproduction - Weebly

    Heredity & Reproduction - Weebly

    TOOLS TO KNOW A PUNNET SQUARE IS A TOOL USED TO PREDICT THE POSSIBLE GENOTYPES FOR THE OFFSPRING OF TWO KNOWN PARENTS. PARENT'S GENES PARENT'S GENES Punnett Squares The Punnett square is the standard way of working out what the...
  • My Senior Project

    My Senior Project

    Once they are done at the drying table, the dogs are groomed to their owners' preference. Pet groomers fall under the category of Animal Care and Service Workers, the job outlook is estimated to grow 15% from 2012 to 2022,...
  • The Information Society Index Measuring a countryÕs capacity ...

    The Information Society Index Measuring a countryÕs capacity ...

    Emerging Virtual Have and Have Not Countries Wilford H. Welch World Times Inc. Stanford University December 1, 1999
  • Ancient Rome Roman Government Essential Standards  6.C&G.1 Understand

    Ancient Rome Roman Government Essential Standards 6.C&G.1 Understand

    6.C&G.1.1 (Government Structure) The Roman Republic was a DEMOCRACY. 6.C&G.1.2 (Political Thoughts) The political thoughts of the Romans were the same for all Democracies. They centered around EQUALITY, LIBERTY, CIVIC PARTICIPATION . 6.C.1.3 (Social Structure) Roman Government worked very closely...
  • Passé Composé with avoir

    Passé Composé with avoir

    To form the negative of passé composé, put ne before the helping verb (avoir or etre) and pas after the helping verb. Subject + ne + helping verb + pas + past participle. Examples. Je n'ai pas étudié. Nous n'avons...
  • First Fridays with the University Budget Office August

    First Fridays with the University Budget Office August

    CLASS - Kathryn Cullivan & Naomi Alvarado. College of Information - Rochelle Sykes. Advancement - Tom Augsburger. Alumni Relations -Margie Lagleder. Research & Innovation - Tori Smith. International Affairs - Jade Lu . Library - AK Khan.