IDD TBI LTSS Care Management Supervisor

Job DescriptionJob Description:

Job Title: IDD TBI LTSS Care Management Supervisor Job Code: ITL SUP Department: Tribal Option/ Primary Care Division: Nursing/Tribal Option Salary Level: Non-Exempt 13 Reports to: Assistant Director of Care Management Last Revised: June 2024 Primary Function This is a new supervisor of care manager positions specializing in providing care management and coordination to individuals with and intellectual and other developmental disabilities (IDD). This position can also serve as an IDD expert as CIHA continues to build out the specialty areas of IDD or TBI (Intellectual & Developmental Disabilities) /TBI (Traumatic Brain Injury). The IDD/TBI (Intellectual & Developmental Disabilities) /TBI (Traumatic Brain Injury) or LTSS (Long Term Support Services) Care Management Supervisor is responsible for the design, implementation, and ongoing operations of services and supports for care managers serving IDD/TBI/LTSS. The position is responsible for supervising care managers who work with individuals with complex chronic IDD/TBI/LTSS diagnoses and their navigation with the medical, pharmacy, behavioral health system and other support systems in the least restrictive environment to meet the needs, desires and wants of the individual. The IDD TBI LTSS Care Management Supervisor shall provide oversight and guidance to the care managers in providing a person-centered approach to identify, service and support needs and link to the most effective service and supports at the appropriate level of care and provide assistance in managing chronic illness and other conditions, provide education about the Person-Centered and “system of care” approaches in collaboration with stakeholders, monitoring person-centered planning effectiveness, quality of care and ensure the use of evidence-based best practice service delivery methods. For Members that also have Tailored care Plan eligibility, the incumbent is responsible for those aspects of care for that member. Job Description • Assure that Care management for Tribal Option, SP, TP, CFSP and other Medicaid individuals with IDD/TBI/LTSS receive industry IDD/TBI standards care management, services and supports that are evidence based, evidence informed or generally acceptable practice. 2 • Build and enhance Care Managers knowledge base, expertise, and capability to provide care management to these specialty populations across multiple disciplines, systems, providers and support entities. • Ensures staff are well trained in and comply with all organizational and department policies, procedures, business processes and workflows. • Ensures that care managers have the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with applicable licensure, regulatory and accreditation requirements as applicable and renewal credits. • Reviews all Individual Support Plans (ISPs) or Person-Centered Plans and provides guidance to care managers on how to meet members’ needs. • Participate in and provide leadership in case staffing for individuals with IDD/TBI/LTSS • Responsible for planning, directing, and organizing the work of supporting care mangers and oversight of services and supports rendered; establish effective professional goals and work plan objectives. • Maintain staffing supporting IDD/TBI/LTSS to meet the needs of the program including personnel administration to include but not limited to recruiting, selecting and managing employees; delegating to staff; encouraging and fostering professional development. • Assures person centered planning methods/strategies are utilized to gather information for individuals supported. Each member will receive integrated, whole- person care management from a single care manager with expertise and training in addressing behavioral health, I/DD/TBI/LTSS needs in addition to physical health needs, unmet health-related resource needs and other entities such as school, vocational and other entities providing supports to the individual. • Assures that care managers consistently complete Discovery activities (information gathering and assessment) in advance of planning meetings and prepares the members for active participation in their care plan meeting. • Assures comprehensive assessments address all required information and are timely completed to identify needs for treatment or monitoring. • Assures timely development of the Person-Centered Plan/Individual Service Plan (ISP) (as applicable). • Assures that assessments/plans are updated, as needed, whenever the individual’s life circumstances change, and documentation is complete and timely in the care management platform. • Assures that the required components of the care managers and the members enrolled in medical homes are in place. These include but not limited to: o Care Coordination o Annual physical exam 3 o Continuous monitoring o Medication Monitoring o Adherence to System of Care components and CIHA Nuka model of care management o Individual and Family Supports o Health Promotion o Addressing unmet health-related resource needs such as securing, referring and coordinating with disability benefits, food and income supports, housing, transportation, employment options, financial literacy, child welfare, rehabilitative services, domestic violence, legal service, service for justice involved individuals, applications, o Overseeing transition and transitional care management for IDD/TBI/LTSS cases o Ensuring the activities of diversion and in-reach occur as applicable o Ensuring that care coordination/management occurs for individuals with co-occurring disorders of IDD/TBI/LTSS and other conditions. o Provide subject matter expertise of ensuring that health IT which includes use of EHR, care management data system and platform, data sources for risk stratification such as ADTs, claims, etc. reflects the uniqueness of IDD/TBI/LTSS. o Utilizes NCCare360 or Tribal equivalent o Provide guidance and expertise for risk stratification in the area of IDD/TBI/LTSS o Provide active and meaningful training and education in the area of IDD/TBI/LTSS o Other activities and tasks required to meet the needs of the population • Review, modify, implement, and maintain a comprehensive training program for care managers of IDD/TBI/LTSS. Provides education and support to care managers of IDD/TBI/LTSS in the following requirements established by NC DHHS and by CIHA. Topics include but not limited to: • Learning about and exercising individual rights, self-advocacy, personal direction, resiliency, and independence. Identifies strategies and tools to prepare individuals/legally responsible persons having information of services available, service options and processes (e.g., requirements for specific service), etc. • Provide information to individuals/legally responsible persons regarding their choice in choosing service providers, ensuring objectivity in the process. • Whole-person health and unmet resource needs • Community integration • Components of Health Home care management • Health promotion 4 • Other Care Management Skills, including specialty for care managers and supervisors serving IDD/TBI, Children, pregnant and postpartum with SUD or SUD history, and LTSS needs. • Adoption of evidence-based evidence informed practices for the individuals being served. • Understanding various I/DD/TBI/LTSS diagnoses and their impact on the individual’s functional abilities, physical health, and behavioral health (i.e., co occurring mental health diagnosis), as well as their impact on the individual’s family and caregivers. • Understanding HCBS, related planning, and 1915(c) services and requirements; Accessing and using assistive technologies to support individuals with an I/DD/TBI/LTSS. • Understanding the changing needs of individuals with and I/DD /TBI/LTSS as they age, including when individuals age out of school-related services; transitional ages of work and retirement • Educating Members with an I/DD/TBI/LTSS about consenting to physical contact and sex. • Methods for coordinating with supported employment resources available through the NC DHHS, the Division for Vocational Rehabilitation, Tribal VOC, and other general employment resources such as the Employment Security Commission. • Provide consultation to the AMH, Tribal Option, and the CIHA care management teams. • Provide continual evaluation of processes and procedures and recommend methods to improve operations, efficiency, and service. • Build, enhance, and monitor key performance metrics, reports, and dashboard to address improvement and adopted PIPs and population health program and initiatives. • Proactively monitor documentation of care mangers to ensure that issues/errors are resolved as quickly as possible. • Conduct onsite visits with providers of IDD/LTSS services rendering services and supports to individuals and make recommendations accordingly to address the care management needs. • Recommend and lead the implementation of care management practices and other tools; identify needs to increase care management effectiveness and efficiency. • Ensures all clinical documentation (e.g., goals, plans, progress notes, etc.) meet state, CIHA and Medicaid requirements. • Conducts record audits and provides guidance to care managers to maintain compliance/quality, as demonstrated by >95% compliance on Qualitative Record Reviews/Chart Audits. • When carrying a small empanelment of members: 5 • Utilizes best practice models to identify, incorporate or develop best practices for panel management. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies. • Manages panel by addressing and resolving acute care needs and chronic care needs through a team based approach. • Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients targeting specific indicators. • Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations • Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care • Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits. Emphasis is placed on ensuring treatment notes are available to the PCP timely. • Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH). • Promotes health care outcomes with currently accepted clinical practice guidelines. • Provides patient education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources. • Assesses patient needs using established clinical guidelines, protocols, and pathways. • Provides appropriate follow up as directed or per established guidelines. • The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System. • Collects data from relevant sources (patient, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in patient center care plan development. • Collects data through observations of appearance and behavior, measurements of physical structure and physiological function, and other information in an effort to place consultations and/or referrals to the correct internal and external resources (Nutrition, Tsali Manor, etc.). 6 • Interprets data and recognizes existing relationships between data collected and the client’s health status and treatment regimen and determines the client’s need for immediate nursing interventions. • Reviews the patient’s health records and health summary, interviewing patients and family members, documenting the chief complaints, medical history, physical and clinical findings, identifying learning needs of the patient and family, and determining priority of care required. Assessment for health prevention, health promotion, restorative, and health maintenance needs is emphasized. • Will plan patient care according to individual assessed patient needs and established hospital policies and procedures. • Develops individualized plan of care with input from the patient, patient’s family, care team members, and anyone else the patient requests to be included for those patients considered “high risk.” • Initiates individualized care plan based on assessment of the patient for specific illnesses, injuries, and diseases and Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care. • Develops expected patient outcomes that are observable and within an adequate period, and are congruent with the patient’s present and potential physical capabilities and behavioral patterns. • Assumes coordination responsibility for transition planning. o Use of ADT including high risk ADT Alerts: ▪ Real time (within minutes/hours) response to notifications of ED visits. ▪ Same-day or next-day outreach for designated high-risk subsets of the population; ▪ Additional outreach within several days after the alert to address outpatient needs or prevent future problems for other patients who have been discharged from a hospital or an ED (e.g., to assist with scheduling appropriate follow-up visits or medication reconciliations post-discharge). • May be required to change work schedule to assist in covering for periodic “late clinics.” • Directs the extender’s care management functions and ensure that the extender supports allowable activities (e.g., coordinating services/appointments by arranging transportation, etc.). • Conducts a care management comprehensive assessment for each member • Develops a care plan (for members without I/DD and TBI needs) or an individual support plan (ISP) (for members with I/DD and TBI needs). o The care plan/ISP will provide a blueprint for ongoing care management and include the member’s health, social, emotional, educational and other service needs. 7 o For members receiving treatment in a congregate setting (e.g., group home or PRTF), the member’s care plan/ISP will also identify the needed services, supports, and timeline to facilitate the member’s transition to a family-based placement, as clinically appropriate. o Include standard timelines that care managers must meet for administering care management comprehensive assessments and developing each member’s care plan/ISP; the required timelines will

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