Targeted Case Management TCM Program Overview 1 TCM

Targeted Case Management (TCM) Program Overview 1

TCM Program Overview The TCM program is governed by the Welfare and Institutions Code § 14132. 44 “. . . case management services that assist Medi-Cal eligible individuals within a specified target group gain access to needed medical, social, educational and other services. Case management services ensure that the changing needs of the Medi-Cal eligible person are addressed on an ongoing basis and appropriate choices are provided among the widest array of options for meeting those needs. ” 2

TCM Program Overview According to Title 42 of the Code of Federal Regulations, Section 440. 169 (d), TCM case management services are comprehensive and each encounter must include at least one or more of the following four service components: o Comprehensive Assessment and Periodic Reassessment o Development of a Specific Care Plan o Referral and Related Activities o Monitoring and Follow Up Activities 3

TCM Program Overview Comprehensive Assessment and Periodic Reassessment: o TCM provides a comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services. These assessment activities include: o Taking client history o Identifying the individual’s needs and completing related documentation 4

TCM Program Overview Comprehensive Assessment and Periodic Reassessment (Continued): o Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual o Assessment and periodic reassessment is to be conducted at a minimum of once every six months to determine if an individual’s needs, conditions, and/or preferences have changed 5

TCM Program Overview Comprehensive Assessment and Periodic Reassessment - Example: o A case manager, during a face-to-face encounter with a client, notices the need for adequate food in the home. 6

TCM Program Overview Development of a Specific Care Plan: A specific care plan is developed by the case manager based on the information collected through the assessment that: o Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual 7

TCM Program Overview Development of a Specific Care Plan (Continued): o Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals o Identifies a course of action to respond to the assessed needs of the eligible individual 8

TCM Program Overview Development o of a Specific Care Plan - Example: A Case manager develops a care plan during a face-to-face encounter and plans to refer client to a food bank for a weekly grocery bag and also refers the client for daily free lunches at a church. 9

TCM Program Overview Referral and Related Activities: TCM provides referral and related activities to help the eligible individual obtain needed services including: o Activities that help link the individual 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. 10

TCM Program Overview Referral o and Related Activities - Example: Case manager during a face-to-face visit calls the food bank and makes arrangements for the client to pick up a bag of groceries for this week and gives information and directions to a church for daily free lunches for the client to utilize. 11

TCM Program Overview Monitoring and Follow Up Activities: Monitoring and follow-up activities/contacts are necessary to adequately address the eligible individual’s needs, and may be done with the individual, family members, service providers, or other entities or individuals and may be conducted as frequently as necessary. 12

TCM Program Overview Monitoring and Follow Up Activities (Continued): They include at least one annual monitoring to determine whether the following conditions are met: o Services are being furnished in accordance with the individual’s care plan o Services in the care plan are adequate o Changes in the needs of status of the individual are reflected in the care plan o Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers 13

TCM Program Overview Monitoring and Follow Up Activities (Continued): o Periodic reviews must be completed at least every six months. These activities may be conducted as specified in the care plan, or as frequently as necessary to ensure execution of the care plan o Monitoring does not include ongoing evaluation or check-in of an individual when all care plan goals have been met 14

TCM Program Overview Monitoring and Follow Up Activities - Example: o In regards to the client going to get the free lunches from a church, the client says she went but will not go again because she did not feel comfortable. The case manager plans to research for other possible resources for free meals. 15

TCM Program Overview The five distinct TCM target populations as: o Children Under the Age of 21 (14) o Medically Fragile Individuals (15) o Individuals at Risk of Institutionalization (16) o Individuals in Jeopardy of Negative Medical or Psycho-Social Outcomes (17) o Individuals with a Communicable Disease (18) 16

TCM Program Overview Children Under the Age of 21 (14): Medi-Cal-eligible children, under the age of 21 years old, who are: At risk for medical compromise due to one of the following conditions: o Failure to take advantage of necessary health care services, or o Non-compliance with their prescribed medical regime, or 17

TCM Program Overview Children Under the Age of 21 (14) (Continued): o An inability to coordinate multiple medical, social and other services due to the existence of an unstable medical condition in need of stabilization, or o An inability to understand medical directions because of comprehension barriers, or o A lack of community support system to assist in appropriate follow-up care at home, or o Substance abuse, or o A victim of abuse, neglect or violence; and In need of assistance in accessing necessary medical, social, educational, or other services, when 18 comprehensive case management is not being

TCM Program Overview Medically Fragile Individuals (15): Medi-Cal-eligible 18 years or older, who are medically fragile, and have multiple diagnoses. Such individuals must also be: o At risk for medical compromise due to one of the following conditions: • Failure to take advantage of necessary health care services, or • Non-compliance with their prescribed medical regime, or 19

TCM Program Overview Medically Fragile Individuals (15) (Continued): • An inability to coordinate multiple medical, social and other services due to the existence of an unstable medical condition in need of stabilization, or • An inability to understand medical directions because of comprehension barriers, or • A lack of community support system to assist in appropriate follow-up care at home, or • Substance abuse, or • A victim of abuse, neglect or violence; and • In need of assistance in accessing necessary medical, social, educational, or other services, 20 when comprehensive case management is not

TCM Program Overview Individuals at Risk of Institutionalization (16): Medi-Cal-eligible individuals, 18 years or older, are in frail health, and meet the following criteria: o Have been identified as needing assistance due to one of the following reasons: • Are in need of assistance to access services in order to prevent medical institutionalization, or • Exhibits an inability to independently handle personal, medical or other affairs, or • Are transitioning to a community setting, who due to socioeconomic status, substance abuse, neglect or violence have failed to take advantage of necessary health care services; and 21

TCM Program Overview Individuals at Risk of Institutionalization (16) (Continued): o At high risk for medical compromise due to one of the following conditions: • Failure to take advantage of necessary health care services, or • Non-compliance with their prescribed medical regime, or • An inability to coordinate multiple medical, social and other services due to the existence of an unstable medical condition in need of stabilization, or • An inability to understand medical directions 22 because of comprehension barriers, or

TCM Program Overview Individuals at Risk of Institutionalization (16) (Continued): • A lack of community support system to assist in appropriate follow-up care at home, or • Substance abuse, or • A victim of abuse, neglect or violence; and o In need of assistance in accessing necessary medical, social, educational, or other services, when comprehensive case management is not being provided elsewhere. 23

TCM Program Overview Individuals in Jeopardy of Negative Health or Psycho-Social Outcomes (17): Medi-Cal-eligible persons who have been determined to be in jeopardy of negative health or psycho-social outcomes due to one of the following disparity factors: o Substance abuse in the immediate environment, or o History of, or in danger of family violence, or o History of danger of physical, sexual or emotional abuse, or o Experiencing substandard housing, or 24 o Illiteracy; and

TCM Program Overview Individuals in Jeopardy of Negative Health or Psycho-Social Outcomes (17) (Continued): Such individuals must be in need of assistance in accessing necessary medical, social, educational, or other services, when comprehensive case management is not being provided elsewhere. 25

TCM Program Overview Individuals with a Communicable Disease (18): Medi-Cal-eligible individuals infected with a communicable disease, including tuberculosis, HIV/AIDS, etc. : or individuals who have been exposed to communicable diseases, until the risk of exposure has passed. Such individuals must also be: o At risk for medical compromise due to one of the following conditions: • Failure to take advantage of necessary health care services, or 26

TCM Program Overview Individuals with a Communicable Disease (18) (Continued): • Non-compliance with their prescribed medical regime, or • An inability to coordinate multiple medical, social and other services due to the existence of an unstable medical condition in need of stabilization, or • An inability to understand medical directions because of comprehension barriers, or • A lack of community support system to assist in appropriate follow-up care at home, or • Substance abuse, or • A victim of abuse, neglect or violence; and 27

TCM Program Overview Individuals with a Communicable Disease (18) (Continued): In need of assistance in accessing necessary medical, social, educational, or other services, when comprehensive case management is not being provided elsewhere. 28

TCM Program Overview TCM Encounter: o An "encounter" is defined as a face-to-face contact or a telephone contact in lieu of a face-to-face contact when environmental considerations preclude a face-to-face encounter for the purpose of rendering one or more targeted case management service components by a case manager. 29

TCM Program Overview Record Retention: o All records in support of allowable TCM services must be maintained for the greater of: (a) three fiscal years after the end of the quarter the LGA receives reimbursement from the DHCS for the expenditures incurred, or (b) three fiscal years after the date of submission of the original or amended TCM cost report, whichever is later, per W&I 14170 30

TCM Program Overview TCM Required Participation Documents: o TCM Annual Participation Prerequisite – July 1 o TCM Provider Participation Agreement – Renewed Every Five Years o Annual TCM Cost Report – November 1 At all times the following documents are required to be on site and available upon request: o TCM Time Survey Training and Documentation o Encounter logs o Client case file documentation 31

TCM Program Overview Reimbursement of Costs: o The costs of providing TCM services to Medi-Cal beneficiaries are reimbursed at the federal medical assistance percentage (FMAP), which is currently fifty percent. o Payment for TCM services must not be duplicated under any other program authorities for the same purposes. 32

TCM Program Overview TCM Program Resources: For more information refer to the sources below or contact your TCM Analyst by emailing the TCM unit at DHCSTCM@DHCS. CA. GOV o California Code of Regulations o Code of Federal Regulations o TCM Website (www. dhcs. ca. gov/tcm) o California Welfare and Institutions Code • W&I Code Section 14132. 44 o Office of Management and Budgets 33 • OMB Circular A-87