TSWF Case Management Pediatric AIM Form Training January Jan-Apr 2019 Form Version These slides were not updated during the May-Aug 2020 release but are still relevant “ Medically Ready Force…Ready Medical Force ”
Dis isclaimer Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data. “ Medically Ready Force…Ready Medical Force ”
Objectives CM/CM Peds Training Objective: Identify the clinical workflows, assessments and tools available in the TSWF CM/CM Peds form CM/CM Peds Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • Verbalize key elements found on the General Assessment tab such as Pain Assessment, ROS, Surgeries/Hospitalizations, and Patient History • Understand the use of other tabs on the form (i.e. Functional Assessment; Pysch/Social Assessment; Health Habits/Wellness etc.) • Describe the purpose and use of the CM Care Plan tab “ Medically Ready Force…Ready Medical Force ”
Why Use TSWF CM Pediatric AIM IM Form? • Provides comprehensive identification of patient care needs (historical and current) to primary and interdisciplinary care teams • Supports dedicated care management requirements through: • Standardized and improved evidence-based documentation • Detection of care coordination requirements • Reduced variance and fragmentation of care management activities • Easy access to references for clinical decision-making • Improved continuity of care and healthcare outcomes • CM Reference links “ Medically Ready Force…Ready Medical Force ”
Why Use TSWF CM Pediatric AIM IM Form? • Critical Tool in Complex CM Core Position Requirements: • Address total needs of patient and family on a regular and recurring basis • Improve collaboration with interdisciplinary teams to improve outcomes • ‘ Proactive management ’ to support and address comprehensive health needs and transition of care requirements, minimize fragmentation, and promote patient safety, quality of care, and cost-effective outcomes “ Medically Ready Force…Ready Medical Force ”
Demonstration of f Form The following slides will walk through each tab of the Case Management Pediatric AIM form. “ Medically Ready Force…Ready Medical Force ”
Resources Form version, links to MilSuite, TSWF Navigator, TSWF Resources, and Change Log are listed at the top “ Medically Ready Force…Ready Medical Force ”
Demographics Tab Screening for CM screening patients Specify whether or not patient is a candidate “ Medically Ready Force…Ready Medical Force ”
Demographics Tab (c (cont.) To type text in an empty field, place cursor near colon/prepositioned text and begin typing “ Medically Ready Force…Ready Medical Force ”
Mil ilitary His istory Tab Documentation to reflect AD member history: Since this is the child’s record, emphasize that this describes the parent(s) and how the child may be impacted during deployments/TDYs. “ Medically Ready Force…Ready Medical Force ”
General Assessment Tab Emphasizes a full system review: Enhanced care planning and needs identification Comprehensive system review includes Dental “ Medically Ready Force…Ready Medical Force ”
General Assessment Tab (c (cont.) Additional documentation to assess needs specific to: • Dietary • Behavioral Health • Episodic care mgmt (Continuity of Care Issue should be investigated) “ Medically Ready Force…Ready Medical Force ”
General Assessment Tab Medical l Con ondit itions Comprehensive review by body system: Allows for individualized identification of specified needs “ Medically Ready Force…Ready Medical Force ”
General Assessment Tab Behavioral l Healt lth Con onditions “ Medically Ready Force…Ready Medical Force ”
General Assessment Tab Additional Medication Do Documentation Full review of medication: • Evaluate understanding and reason for prescribed meds “ Medically Ready Force…Ready Medical Force ”
Functional Assessment Tab Specify ADL capabilities ‘Requiring Assistance’ box: CMs documentation required in the event the child is dependent “ Medically Ready Force…Ready Medical Force ”
Functional Assessment Tab (c (cont.) Assess Living arrangements: • Ensure ongoing medical care support is available in the event the primary home of record changes, to ensure continuity of care is uninterrupted. “ Medically Ready Force…Ready Medical Force ”
Functional Assessment Tab DM DME Durable Medical Equipment (DME) specific details and needs can be documented here “ Medically Ready Force…Ready Medical Force ”
Functional Assessment Tab DM DME (c (cont.) “ Medically Ready Force…Ready Medical Force ”
Psych/Soc Assessment Tab Psych/Social Tab: • Opportunity to assess additional family or Behavioral Health support, if needed “ Medically Ready Force…Ready Medical Force ”
Psych/Soc Assessment Tab (c (cont.) If patient is a student, document this as occupation, grade, type of schooling; daycare, homeschool, public, private, etc. “ Medically Ready Force…Ready Medical Force ”
Psych/Soc Assessment Tab Environmental l Con oncerns Comprehensive Environmental assessment should be completed and routinely reassessed to identify potential ‘triggers’ that could exacerbate existing conditions. “ Medically Ready Force…Ready Medical Force ”
Health Habits/Wellness/Misc Tab Health Habits Assessment: • Assess patient’s needs • Coordinate any gaps with immunizations with the PCMH team and document “ Medically Ready Force…Ready Medical Force ”
Health Habits/Wellness/Misc Tab Alc lcohol Enter AUDIT-C date and score here Beneficiaries who consume alcohol should complete an Audit C. The Case Manager should coordinate results back to PCMH Team. “ Medically Ready Force…Ready Medical Force ”
Health Habits/Wellness/Misc Tab Tobacco Assess for alcohol or tobacco use. If identified, documentation should include: • Coordination with the Primary Care Provider/Team • Resources/Benefits available to eligible beneficiaries and follow-up “ Medically Ready Force…Ready Medical Force ”
Care Team Tab “ Medically Ready Force…Ready Medical Force ”
Care Team Tab Sp Special l Se Services/Referrals ls Comprehensive evaluation of specialized services is available. Utilize the ‘Other’ section to identify additional services, if needed. “ Medically Ready Force…Ready Medical Force ”
CM Care Pla lan Tab The CM workflow is to address each problem with a separate care plan. The narrative and Recommend updates quickly reach the using this format 2000 word limit. It is not recommend to add multiple plans to the same field. “ Medically Ready Force…Ready Medical Force ”
CM Care Pla lan Tab A care plan outline can be pasted here (place cursor in top left corner and paste). Be sure to answer care plan review question when pertinent. Answer diagnosis/prognosis question if applicable. If answer is ‘ no, ’ you may need to address as a barrier to care. “ Medically Ready Force…Ready Medical Force ”
CM Care Pla lan Tab (A (Army Additional Do Documentation) Required for Army WTU CM Documentation (Information applies to Service Member) “ Medically Ready Force…Ready Medical Force ”
Defi finitions Tab “ Medically Ready Force…Ready Medical Force ”
TSWF Resource Material The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/ “ Medically Ready Force…Ready Medical Force ”
Pri rimary Care Clinical Community Content Working Group ▪ DHA - Maj Matthew J Royall ▪ ARMY - Dr. Robert Marshall ▪ AIR FORCE – Dr. Matthew Barnes TSWF Feedback https://www.milsuite.mil/book/groups/tswf TSWF Website http://www.tswf-mhs.com/ “ Medically Ready Force…Ready Medical Force ”
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