What Is TCM And How It Can Help You
Targeted Case Management (TCM) is consists of services that assist eligible beneficiaries in securing medical, social, educational and other health services necessary to appropriate care and treatment. Case management is not directly connected with providing the care and services, but instead is a separate and reimbursable type of service under Medicaid that for specific beneficiaries, identifies the appropriate services, assists in locating those services, identifies providers, and monitors the provision of care.
Case management services have historically been understood to be a separate administrative activity under Medicaid provisions governing the relationship between Medicaid agencies and state maternal and child health agencies. Fundamentally, it is a form of public health nursing.
Case Management has existed as a separate, reimbursable system of medical assistance programs since 1985. Congressional amendments initially made targeted case management (TCM) services (that is, case management services targeted to specific population subgroups) a payable class of medical assistance services when furnished as part of state waiver program §1915.6. Congress subsequently amended Medicaid to permit states to provide targeted case management services as a coverage option, regardless of whether coverage was offered in connection with a waiver program. The Congressional Research Service (CRS) notes that almost all states cover TCM services.
TCM has remained an ongoing concern for both the executive and legislative branches. For example, the Bush Administration proposed legislative changes to reduce Medicaid TCM expenditures in its annual budget submissions. In the Deficit Reduction Act (DRA) of 2005, Congress included statutory language to clarify the definition of case management and directed the Secretary of Health and Human Services to promulgate regulations to guide states’ claims for federal Medicaid matching funds for TCM. As a result of DRA requirements, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule on December 4th, 2007 for case management, which was taken into effect on March 3rd, 2008.
Who is TCM services aimed at?
TCM services are targeted at the following individuals nationwide:
• Individuals with Intellectual and Related Disabilities
• At Risk Children
• Adults with Serious and Persistent Mental Illness
• At Risk Pregnant Women and Infants
• Individuals with Psychoactive Substance Disorder
• Individuals at Risk for Genetic Disorders
• Individuals with Head and Spinal Cord Injuries and Related Disabilities
• Individuals with Sensory Impairments
• Adults with Functional Impairments
Case Management Interim Final Rule
The case management interim final rules elaborate on changes to the TCM definition authorized and initiated in DRA by producing specific guidance on how states may claim federal financial participation (FFP) for TCM expenditures. This also addresses case management problems that previously may have been considered open to interpretation. CMS states that the case management interim final rule applies to all Medicaid authorities, so that all case management, including TCM and services delivered through waivers, would be covered under the rule. Some of the changes handled in the proposed rule are outlined below.
Institutional Care
Federal financial participation (FFP) would be paid for case management provided for individuals who reside in community areas or who want to transition from institutions to community locations. Generally, states may not receive FFP for beneficiaries residing in inpatient acute care facilities, although there is an exception for individuals with complex or chronic medical requirements. The interim final rule allows states to receive FFP to assist individuals who are able to transition from an institution to a community setting. This provision would allow states to claim FFP to assist individuals in transitioning to community settings during either the last 14 days (for beneficiaries who are institutionalized for short-term stays) or the last 60 days (for those who are institutionalized for long-term stays). Although, for states to receive FFP for beneficiaries transitioning to the community, the beneficiary must receive the TCM services for a term that span their inpatient and community placement. Additionally, FPP would be payable only after the date on which beneficiaries community residence begins. The state is allowed to use TCM to help coordinate other services, such as housing and transportation, for individuals transitioning to a community setting.
Case Managers
The states are required to establish qualifications for providers who deliver case management services. Additionally, the rule states that the services case managers can provide, such as assessment to determine the recipient’s needs, development of specific care plans, referral, and related planning process, as well as to reduce fragmentation and maintain quality of care, states would need to assign each person only one case manager. Although, case managers may not serve as gatekeepers or make medical necessity determinations. Furthermore, beneficiaries must have free choice of all qualified case managers, and beneficiaries’ access to case management cannot be contingent upon the use of certain providers. If beneficiaries fit in several target groups, states must decide which target group they should be assigned to. The regulation would have allowed for a delayed compliance date for states to transition to one case manager to provide comprehensive services for individuals. TCM case managers may not provide direct medical and related services unless such services are billed to Medicaid as services other than case management.
Treatment Plans
Those who benefit from Medicaid case management services must have treatment plans. Case management excludes diagnostic testing (but testing may be covered under other Medicaid benefit categories.) Case managers must maintain detailed case records that document the recipient's dates of service, progress towards treatment goals, units of case management delivered, timelines for services described in the treatment plan, as well as reassessment dates; and the need for coordination with case managers of other programs.
TCM Rule Using Common Case Management Elements
States have pursued programs that target the aged, blind and disabled (ABD) and/or Supplemental Security Income (SSI) eligible beneficiaries as a way to more appropriately manage the care needs of these complex populations. Many of these programs will possibly be affected by the TCM rule.
Care Coordination Availability
Care coordination is commonly available on a 24/7 basis. This degree of availability may likely end since the same care manager would effectively need to be on duty for 24/7 basis.
Cross-Service Coordination
Often times, care managers make housing referrals and assist with relocation. Furthermore, care managers are often responsible for assisting the beneficiary with pharmaceutical management, routine monitoring of their condition, and referrals to additional ancillary services.
Intensive Case Management
This service is usually offered for a more intensive level of support for individuals with a serious mental illness who may or may not have significant substance abuse challenges. Intensive case management is recommended for persons who have experienced chronic homelessness and have frequent crisis. These individuals may be unable to obtain or maintain a safe area to live or to identify, access and utilize needed treatment, family and/or community services.
Resource Coordination
A less intensive level of support exists primarily for individuals who may also have minor substance abuse issues and mild to moderate difficulty gaining access to mental health treatment, and require temporary support to assess, access and utilize needed treatment, family and/or community services. Prevention and Recovery Services (PARS) provides services to individuals who suffer from serious mental illness and have experienced a problem in their ongoing Mental Health treatment or individuals who may be experiencing an initially lMH episode and need to be connected with services for the first time.
Children’s Case Management Services
Specialized case management services for children and adolescents that deal with serious mental illness and/or substance abuse-related problems. Intensive Case Management is available 24/7 usually to see children with behavioral challenges. ICM’s connect children and their families to needed mental health services as well as other community resources and support. The ICM interfaces and advocates quite regularly with other relevant systems such as Intellectual disability Services, Juvenile Justice, the local school system, and the Department of Human Services.
Community Treatment Teams
Multi-disciplinary teams that provide personalized and intensive case management services to help adults with serious and ongoing mental illnesses, often in conjunction with serious substance abuse and/or medical challenges. A high-intensity service recommended for individuals who experience frequent hospitalizations, crisis visits, and mobile emergency services. These teams provide 24/7 service accessibility. Services can include, but are not limited to case management, medication management, housing support, employment counseling and more.
Why Does Targeted Case Management Matter?
Whether the phrase is used for targeting individuals or populations is less important than the fact that this is a part of the personalized medicine revolution that is still affecting our society today. Social service providers at all levels have come to recognize that a one-size-fits-all case management solution is very outdated. Instead, by utilizing targeted case management, case managers are beginning to think in terms of solutions that are specific to the needs of the individual or group they are serving.
Benefits of TCM
The digital information and connectivity reformation made it possible to avoid the annoying hiccup that used to crop up at various points during a patient’s interaction with healthcare providers and insurance providers. On the care side, developing a case for each patient and collecting critical information in one accessible location helps the provider plan a course of action after diagnosis, provides the capability to evaluate and track treatment as well as track and evaluate the overall effectiveness of the care.
Over the past couple of years, various health agencies have been able to seamlessly share that information, allowing for better and safer care across disciplines. For example, if the primary care physicians can see diagnoses and prescriptions from the gastroenterologist, developing a more comprehensive health strategy becomes possible. That coordination can improve prescription accuracy and tracking, prevent unnecessary tests and procedures, and ultimately help patients lead healthier lives. On the insurance side, the case management process helps the insurer track treatments and coordinate care to improve quality and lower costs.
Conclusion
The world of case management is always changing, and the transformation towards an outcome-based approach means that targeted case management is becoming a growing issue more than ever. By personalizing the inputs to the needs of the individual or population that is being served, the outputs can be vastly improved, resulting in much better services across the board. It’s no longer enough for a single case management solution. We live in an era where targeted case management is the leading game-changer.