Case Management as a Cornerstone of Care

By Nancy Ross Bell, RN

Estimated time to read: 5 minutes

Case management (CM) services are a cornerstone of person-centered care across the healthcare spectrum. CM service organizations must base their programs on population-based data, clinical evidence, and proven quality and process outcomes.  

This blog focuses on organizations with standalone NCQA CM Accreditation and standards CM 1-CM 9. NCQA considers entities that perform relevant CM functions to be eligible for NCQA CM Accreditation, including, but not limited to, CM organizations, population health management (PHM) organizations, health plans, managed behavioral health organizations (MBHOs), provider-based organizations (medical groups, hospitals, integrated delivery systems, patient-centered medical homes, and accountable care organizations), and community care teams (2020 CM Policies and Procedures).

As of this writing, NCQA’s Report Card lists 72 CM organizations that are  NCQA CM-Accredited, with additional in process or scheduled. What makes them unique is about half also hold NCQA Accreditation for other programs, such as Credentialing/CVO, Health Equity, Population Health Programs, Utilization Management, and Wellness and Health Promotion.

Additional NCQA Programs Addressing Case Management

In addition to NCQA’s standalone CM Accreditation program, CM is addressed in other programs. To clarify, these programs are: 

• NCQA Accreditation of CM for Long-Term Services and Supports (LTSS) is for community-based organizations where alignment with state regulations on person-centered long-term care is imperative (LTSS 1-LTSS 8). Organizations applying for Accreditation of CM for LTSS offer a broad range of supportive services for individuals who have difficulty completing self-care tasks resulting from aging, chronic illness, or disability. Support services may last from weeks to years.
  • NCQA Health Plan (HP) Accreditation includes standards on Complex Case Management (CCM) in the Population Health Management Standards (PHM 5 Elements A – E). Complex case management is for members who have experienced a critical event or diagnosis that requires extensive use of resources.
  • Separately, health plans may achieve LTSS Distinction for coordinating long-term services and support with community service providers, clinicians, and caregivers.
  • NCQA Managed Behavioral Healthcare Organization (MBHO) Accreditation includes complex case management in the Quality Management and Improvement Standards (QI 8 Elements A – J).

Key Points Not to Miss on NCQA CM Accreditation Standards   

Nine standards form the framework for NCQA CM Accreditation, some of which are highlighted below. For full details, always refer to the most current NCQA standards on CM Accreditation, available in the NCQA Store.

CM Program Descriptions Tell the Story of What You Offer (CM 1)

Your CM Program Description is the detailed narrative about each program your organization offers, program goals, internal processes, and staff involvement (CM 1A).

Make your program goals meaningful. Using SMART goals for each CM program communicates objectives and targets across the organization (CM 1A Factor 4). 

SMART goals are:

• Specific
• Measurable
• Achievable
• Relevant
• Time-bound

For example, a program goal for the CM organization is to ensure a highly satisfied patient experience for individuals discharged from an acute inpatient stay by providing complete care plans that document their needs.

A SMART goal may be:

• Program: Transitional Care/Post-Acute Stay Care Coordination
• Specific: Service needs are arranged 24 hours before a planned discharge
• Measurable: At least 24 hours before discharge, functional status is assessed, and follow-up appointments, referrals to community resources, self-management instructions, and medication reconciliation are completed and documented by the case manager. The patient and/or caregiver verbalize understanding.
• Achievable: Service needs are arranged and communicated within 24 hours of discharge and are incorporated into a care plan.
• Relevant: A thorough and completed case management plan understood by the patient and caregiver helps prevent readmission and promotes the patient experience.
• Time-bound: System triggers are established upon admission with alerts to begin post-acute care coordination within an estimated discharge time. The transitional care plan is completed 24 hours before a planned discharge.

Key Points: CM Program Descriptions:

• Program Descriptions must be updated regularly (CM 1 Intent).
• The Look-Back Period (LBP) for Initial surveys is 6 months and 24 months for Renewal surveys.
• Program Descriptions must cover the beginning of the LBP, which could mean including three descriptions for Renewal surveys if updated annually.
• A Program Description must be documented for each of the organization’s programs. The score for CM 1A is the average of all programs brought forth (CM 1A Scope).
• Each Program Description must define the services offered and program goals (CM 1A Factors 3 and 4).
• SMART goals help keep organizations accountable.

Looking at Guidelines, Pathways, Literature Reviews, and Research

The initial development of the CM programs is based on scientific evidence (Critical Factor - CM 1A Factor 2).  

Key Points: CM Evidence-Based Criteria

• Following the initial development of CM programs, organizations pursuing Renewal surveys must engage at least two appropriate practitioners to review and discuss updates to the scientific evidence at least every two years to fulfill the 24-month LBP (CM 1B Factor 1).
• Ensure that practitioners used to review evidence are appropriate to the program. For example, the American Diabetes Association (ADA) published updates and changes in the Standards of Care in Diabetes-2023. Appropriate practitioners could include those within an NCQA-Recognized Diabetes practice.
• Following the review of scientific evidence, review and update the program content, member materials, and training materials to ensure they are consistent with evidence-based criteria and are culturally and linguistically appropriate.

TIP:  Establish alerts and assign accountability for the timely review of scientific evidence.  A calendar of tasks used by quality committees, such as one offered by MHR, can keep you on track.

Population, Patients, and Initial Assessment (CM 2)

After developing the CM programs, a Population Assessment is conducted to identify the characteristics and needs of the organization’s eligible populations and relevant subpopulations. The full Assessment is done annually using available data and information. Based on findings, CM programs are reviewed, and process and resource updates are made (CM 2A Factors 1 through 3).

For example, an organization may have identified a subpopulation of dual-eligible Medicare/Medicaid individuals over the age of 80 with impaired mobility and vision who require case management after acute inpatient stays. External resources to meet this subpopulation’s needs must be assessed and updated as necessary.

Need assistance conducting a Population Assessment?  MHR has a proprietary template to walk you through the steps. In more than 20 pages, you will find instructions, resources, and tables to record your data and guide you to conclusions on your population.

Following the Population Assessment, data is routinely mined from nine available sources to proactively identify patients for each CM program (CM 2B Factors 1 through 9). Note that this process is required for each CM program. The score for CM 2B is the average of the scores for all programs.

To identify patients who qualify for each CM program, organizations must demonstrate that they followed the process described in CM 2B. To be scored at 100% for CM 1C, the systematic process to identify patients for CM programs must be done and reported at least monthly.

Key Points: Populations and Patients

• A Population Assessment is conducted and reported
• CM program materials are reviewed and updated based on the annual assessment of the population and subpopulation characteristics and needs.
• For Renewal surveys, the most recent year and previous year’s Assessment reports, as well as evidence such as minutes demonstrating the process, are submitted.
• A Policy and Procedure for the mining of data to identify patients for CM explains the details in CM 2B Factors 1 through 9. NCQA reviews evidence that the organization followed its process to identify patients for each program.

After identifying the organization’s eligible populations and subpopulations, each patient is assessed in detail according to its Policy and Procedure on the Initial Assessment Process.  The Initial Assessment Process includes 12 Factors in CM 2D and lays the foundation for personalized care. Ensure that all bullet points described within the Explanation are included when documenting your process.

Take, for example, CM 2D Factor 3, which calls for describing the process of how functional status is assessed for at least six basic activities of daily living (ADL), including bathing, dressing, going to the toilet, transferring, feeding, and continence. An organization may include common words in its process for staff to use during an assessment. Using bathing as an example, bathing could also mean washing, showering, or soaking in a bathtub.

Tips-Initial Assessment Process:

Within the Explanation in CM 2D, note the following:

• The assessment and evaluation Factors each require a case manager or other qualified individual to draw and document a conclusion about the data or information collected.
• Clinical histories require a process to document dates.

Finally, the organization demonstrates its adherence to its Policy and Procedure on Initial Assessment through File Reviews in CM 2E Factors 1 through 12.  File reviews are high-point standards showing that you did what you said you would do.

Key Points: Initial Assessment Process

• A formal Policy describes the overarching course of action the organization will follow for its CM Initial Assessment process. It must be formally adopted by the organization with a documented effective date.
• A Procedure describes how staff will carry out actions to achieve the objectives stated in the Policy. Like the Policy, include an effective date for the Procedure, understanding that Procedures may change over time even though the Policy remains the same.
• The Policy and Procedure must cover the entirety of the 24-month LBP for Renewal surveys and 6 months for Initial surveys.
• MHR recommends aligning your Policies and Procedures with details in the Explanation (CM 2D Factors 1 through 12).
• As you write your Policies and Procedures, review how files will be assessed in CM 2E, where you demonstrate your adherence to your processes.
• As an organization’s internal processes, IT systems, and staffing may change during the LBP, it is critical to update your Policy and Procedure and avoid gaps that can occur with changes.
• Any change in the Assessment process should trigger an internal audit of files to ensure compliance with a new process.

Care Planning Process (CM 3A) & Case Management-Systems (CM 4A) and Ongoing Management (CM 4B)

Individualized care plans are patients' “blueprints” for case management. The data collected in the Initial Assessment in CM 2 is transformed into the individual plan. When patients actively participate in their care plans to the extent possible, the potential to meet goals will likely increase.

The organization’s Policy and Procedure for Care Planning is described in detail, including all bullet points in the Explanation for CM 3A Factors 1 through 6.  (Refer to “Key Points: Initial Assessment Process” for guidance when developing a Policy and Procedure for Care Planning.)

Pay particular attention to:

• Prioritizing goals
• Clarity of barriers and actions to address
• Timeframes and schedules for reevaluation and follow-up communications

The organization’s Care Planning Process described in CM 3A is then evaluated through File Review in CM 4B.

Tips-File Reviews (CM 2E and CM 4B)

• Pay close attention to the file universes that are within the scope of CM 2E and CM 4B.
• NCQA randomly selects up to 40 CM files for each file review.
• Files include active or closed cases identified during the LBP and remained open for at least 60 calendar days during the LBP.
• The 60 day timeframe starts when the patient was identified for CM. The identification date must be provided for each case in the file universe.
• Case Managers must document their own conclusions even if their CM system produces an automated conclusion.

Best Practices

• File Universes: MHR has found that identifying the correct file universe can sometimes be challenging. Don’t risk the reviews – ask MHR to verify your file universes during our consultation.
• Mock File Audit: Why wait for your NCQA survey to confirm you are following your Policies and Procedures, or in the worst case scenario, finding deficiencies that must be corrected at the “last minute”? By using MHR’s proprietary File Review Guides and File Review Audit Tools, you can have the peace of mind you need for your CM files.

Systems Check (CM 4A)

CM Systems that support the CM process are evaluated for three factors:

• Evidence-based guidelines or algorithms used to conduct assessment and management are embedded in the system
• Automated features for each entry and use of automatic date, time, and user ID or name
• Automated prompts or reminders for next steps or follow-up care

Required by the organization are a Policy and Procedure on how monitoring is done, reports of automated documentation and prompts throughout the Look-Back Period, and annotated screenshots showing the system functionality.

Avoid Unplanned Transitions of Care (CM 5)

“Safety is our number one priority” is often heard across the healthcare industry. Transitional case management programs and programs for high-risk and high-utilization of emergency department and inpatient services can be instrumental in coordinating post-hospitalization needs for patients at risk for an unplanned transition. 

Care Transitions includes these steps:

• Define the Policy and Procedure for managing planned and unplanned transitions (CM 5A)
• Identifying patients at high risk and taking action to prevent unplanned transitions (CM 5B)
• Analyzing rates of unplanned transitions for the population and taking action to improve (CM 5C)

Key Points: Care Transitions

• Collaborating with the discharge team on the discharge plan (CM 5A Factor 7) is a Critical Factor. The process to resume or initiate services must be described.
• Consider all settings in which a transition may occur, understanding that the receiving setting is responsible for care after a transition. For example, the process for transitioning to home and community may differ from that of skilled nursing facilities.
• Identifying high-risk patients must be reported at least monthly (CM 5B Factor 1).
• Reducing unplanned transitions for the population requires a quantitative and qualitative (Q&Q) analysis of admission rates to facilities and emergency room visits for the population that receives services (CM 5C Factors 1 & 2).

Read more on transitions of care in our blog:

 Prevent Unplanned Transitions of Care (April 18, 2023)

Measurement and Quality Improvement (CM 6)

Annually, the CM organization conducts Q&Q analyses of patient experience based on data collected through focus groups, experience surveys, and individual patient complaints.

In addition, at least three measures that have significant bearing on the CM program’s population or a defined subset of the population are selected and evaluated, and performance goals are set. At least one intervention each is decided to improve clinical performance and patient experience. Remeasurement determines the impact on clinical performance and patient experience (CM 6 ABC).

The CM organization is transparent with its clients on the methods used to calculate the effectiveness of each CM program (CM 6D)

Up to three reports are reviewed by NCQA, assessing the inclusion of:

• The definition of the population included in the denominator
• How patients are placed in the numerator
• The time periods affecting numerators and denominators

An additional measurement is that of patient participation in the CM programs. This measure evaluates the rate of actively engaged patients compared to eligible patients. When participation thrives, so does your program’s impact.

Many organizations find Q&Q Analysis challenging. MHR has a template for Analysis that meets NCQA Accreditation requirements.

Staffing, Training, and Verification (CM 7)

Appropriate staffing for CM organizations is dependent on the needs of the population, the number and licensure of staff to provide CM services, and the initial and ongoing training specific to the CM programs.

Key Points: Staffing, Training, and Verification

• The Population Assessment conducted in CM 2 drives the staffing model. The staffing model for each CM program may differ. For example, elderly patients in cognitive decline may benefit from a case manager experienced in elder care.
• The organization’s documented process states the categories and numbers of staff needed by licensure or non-licensure. For example, patients discharged after uncontrolled diabetes will likely need a dietician.
• Annual and ongoing training with semiannual feedback to staff on performance is required.
• NCQA evaluates the organization’s verification of licensure through random sampling of licensed personnel during the LBP, which is 36 months for both Initial and Renewal Surveys.
• A Policy and Procedure specifies the frequency and process for ongoing monitoring for licensure, sanctions, and complaints and details of action taken if issues are identified (CM 7F)

Having the right tool to verify staff credentials prompts compliance with meeting the 90 calendar days of hiring. MHR has the tool you need.

Rights and Responsibilities (CM 8)

NCQA reviews the organization’s Policy and Procedure for providing patients with their rights and responsibilities for the CM program and the materials used in communicating these rights (CM 8A and B).

Critical to patient rights is describing how the organization registers and responds to complaints (CM 8C). Ensure all Factors are clearly described in the Policy, including the turnaround time for resolving complaints.

Organizations are held accountable by reporting complaint resolution and timeliness in CM 8D.

Call to Action:

Schedule now for MHR’s:

• Consultation for NCQA CM Accreditation includes an assessment of your documentation against standards, a sample audit of all file reviews, and recommendations for next steps.
• Training on NCQA CM Accreditation is also available by one of our clinical consultants.
• Training on NCQA Delegation or NCQA Analysis

Go to the MHR Products tab for available tools and templates, and training.

Contact your MHR Consultant or email us at [email protected]

Resources:

• NCQA CM Accreditation 2020 Standards and Guidelines and Appendices 1 through 4
• MHR Blog: Getting Delegation “Right” (January 18, 2023)
• MHR Blog: Prevent Unplanned Transitions of Care (April 18, 2023)
• MHR Blog: Be Confident in the Driver’s Seat with NCQA File Reviews (March 19, 2024)

MHR Clinical Consultant Erin Kafieh, RN, participated in the quality review process for this blog. Please read more about Erin and MHR’s other Independent Consultants at ManagedHealthCareResources.com/About Our Consultants 

MHR: Driving healthcare quality one NCQA accreditation at a time