A. A medical risk
screen must be conducted to determine the need to refer an individual for
Targeted Case Management (TCM) services. Referrals for TCM services must be
initiated during the pregnancy for the woman, or birth through one (1) year of
age for the infant. The medical risk screen must:
1. Be completed by a physician, physician
assistant, a nurse practitioner, or certified nurse-midwife,
2. Only be conducted once per pregnancy
unless the beneficiary changes providers and the new provider is unable to
obtain the beneficiary's medical records, and
3. Be completed up to two (2) times for
infants, if risk factors are present.
B. Targeted Case Management is a
collaborative process of assessment, care planning, care coordination, and
evaluation of services to meet the identified needs of eligible women who are
pregnant and up to sixty (60) days postpartum or infants from birth through (1)
year of age. TCM activities include:
1. An
initial comprehensive assessment that is beyond risk screening must be
conducted to determine the specific needs of the participant and identify
which, if any, referrals for extended or other services are needed. The initial
comprehensive assessment must, at a minimum:
a) Be performed by the RN case
manager,
b) Be completed within
fifteen (15) calendar days after the referral is received for TCM,
and
c) Be maintained in the
participant's case record.
2. A Plan of Care (POC) must be developed and
periodically updated which, at a minimum:
a)
Reflects the specific needs identified through applicable
assessments,
b) Establishes
specific goals (long and short-term),
c) Includes interventions to address the
participant's goals and meet the identified needs,
d) Must be action oriented with identifiable
outcomes that are measurable and achievable within a manageable time
frame,
e) Must be updated timely to
reflect changes in the participant's needs or status,
f) Identifies each interdisciplinary team
member's responsibilities in addressing identified needs, and
g) Provides a personalized discharge plan
that, at a minimum, identifies all goals or needs that extend beyond case
closure. Processes must be in place to coordinate appropriate linkages and
services prior to case closure. Discharge planning must be documented in the
case file.
3. Care
Coordination includes regular communication, information-sharing, and
collaboration between case management and others serving the participant,
within a single agency or among several community-based agencies. All care
coordination activities must be recorded in the case file and must, at a
minimum include:
a) Regular communication with
the participant, participant's family or authorized representative,
provider(s), and the interdisciplinary team,
b) Coordinating access to services and
benefits, reducing barriers, and establishing linkages with other services
providers,
c) Referrals and related
activities including, but not limited to, scheduling appointments to help the
participant obtain needed services and linking the participant with medical,
social, educational, or other program(s) or resource(s) that are capable of
providing needed services to address identified needs and achieve goals
specified in the POC,
d) Revising
the POC to reflect the changes in the needs or status of the
participant,
e) Processes for
participant transfer to a new TCM provider, if chosen, and
f) Making appropriate referrals as needed and
upon case closure to ensure continuation of care.
4. Monitoring and follow-up activities
include activities and contacts that are necessary to ensure the POC is
implemented and adequately addresses the participant's needs. Activities may be
with the participant, the participant's personal or authorized representative,
or the participant's service provider and must be conducted at least monthly
and more often as necessary. Monitoring and follow-up activities include, but
are not limited to:
a) Monthly face-to-face
contact with the participant,
b)
Monthly case conference with the interdisciplinary team,
c) Initial contact with the participant's
primary care provider(s) upon enrollment into the program and continued
communication with the primary care provider(s) if the participant's condition
or status changes,
d) Routine
review and follow-up of case notes from all service providers, and
e) Review and revision of the POC routinely
and as needed.
C. Extended services for eligible
participants who are pregnant and up to sixty (60) days postpartum or infants
from birth through one (1) year of age are based upon the specific needs
identified on the initial comprehensive assessment.
1. Appropriate referral(s) for extended
services must be initiated by the case manager.
2. Any extended service(s) being provided
must be included in the POC and evaluated by the case manager at least monthly.
Extended services include:
a) Initial nursing
assessment and evaluation performed by a registered nurse (RN) within ten (10)
business days from referral,
b)
Nursing services performed by an RN which must include health
education,
c) Home visit for
postpartum assessment and follow-up performed by an RN,
d) Nutritional assessment and counseling
performed by a registered dietician or licensed nutritionist within ten (10)
business days from referral,
e)
Nutritional counseling and dietician visit performed by a registered dietician
or licensed nutritionist,
f) Mental
health assessment performed by a non-physician practitioner within ten (10)
business days from referral, and
g)
Behavioral health prevention education services performed by a mental health
professional.
Miss. Code
Ann. §§
43-13-121,
43-13-117(19)(a);
42 CFR §
440.169.