Definition of Scopes
- Face-to-Face office visit
Definition:Face-to-face encounter between client and case manager at case manager’s office. This encounter may be formal or informal but should emphasize a process by which to assess, coordinate, implement, and/or monitor care options and services that meet the needs of the client.
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spent with client
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag: Yes
Contact Party: Client
Contact Type: Office
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Face-to-Face Medical Accompaniment
Definition: Case Manager accompaniment of either a newly diagnosed or lost to care client to a medical appointment. A newly diagnosed client is a client that has been diagnosed within the last 18 months. A lost to care client is a client that has not had a medical appointment within the last 6 months.
Documentation:
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spent with client
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag: Yes
Contact Party: Client
Contact Type: Clinic
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Face-to-Face Home Visit
Definition:Case Management home visit for clients with special needs, impairments, or recovering from an intensive medical procedure that prevents/impairs commute to case management office.
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spent with client
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag: Yes
Contact Party: Client
Contact Type: Home
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Face-to-Face Discharge
Definition: Closure of clients who have either successfully completed care plan goals and have become self-sufficient or for individuals that need to be administratively or situationally discharged. A definition of each type of discharge is documented below:
a)Self-Sufficient Discharge-Clients that are adherent to their medication and medical appointments and no longer perceive any direct barriers to their care
b)Administrative Discharge-Clients with major behavioral issues that prevented their continued involvement in case management services
c)Situational Discharge-Clients that are deceased, lost to care, or disengaged and theirwhereabouts unknown
For a client to be discharged, a face-to-face meeting with the client, case manager and case manager supervisor will take place to ascertain the reason for the discharge. Case Manager and Case Manager Supervisor will complete and sign off on the discharge paperwork and will scan in the discharge sheet into Provide.Additionally, the Case Manager will write a progress log describing the reason for the discharge as well a description/update on all care plan goals that were met/unmet.
Provide Documentation:
Create Sub Record > Scan
Attach discharge form under Miscellaneous scan
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spent with client
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag: Yes
Contact Party: Client
Contact Type: Discharge
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Face-to-Face CM Care Conference
Definition: A formal face-to-face collateral contact with another licensed provider(s) directly involved in the client’s care. Examples of licensed providers include mental health therapists, substance abuse counselors, housing case managers, etc.
If a care conference includes a physician as one of the present providers, code this as care coordination with primary care provider.
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spentdiscussing the client’s care
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag: Yes
Contact Party: Collateral
Contact Type: CM Conference
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Telephone/Text/Email Contact
Definition: Non face-to-face contacts or attempted contacts between case manager and clients involving monthly check ups, well-being checks, referral follow-up and/or follow-up adherence counseling.
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spent with client
Note Type: Case Management Note
Contact Flag: Made or Attempted
Face-to-Face Flag: No
Contact Party: Client
Contact Type: Telephone/Text/Email
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Face-to-Face Other Visits
Definition: Face-to-Face encounter between case manager and client at a designated location other than office or home setting. Examples of locations designated as other are substance abuse or mental health facilities, nursing home/hospices, halfway house, emergency rooms, etc.
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes: Must be the actual amount of time spent with client
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag: Yes
Contact Party: Client
Contact Type: Other
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description: Concise statement summarizing progress note
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Care Coordination with Primary Care Provider
Documentation:A formal or informal face-to-face or telephone contact with a client’s primary care provider or HIV specialist to discuss/communicate information about the client’s care. The primary care provider may be a physician, advanced practice registered nurse, or physician assistant who provides primary health care to the client.
If a care conference includes a physician as one of the present providers, code this as care coordination with primary care provider.
1)Scan in the AFC medical form
Provide Documentation:
Create Sub Record > Scan
Scan in and attach the AFC 2-page medical form
2)Progress log
Provide Documentation:
Create Activity > Progress Log
Provider: Name of Case Manager
Date: Must be the actual date of meeting
Start Time: Must be the actual start time of meeting
Minutes:Must be the actual amount of time spent discussing the client’s care
Note Type: Case Management Note
Contact Flag: Made
Face-to-Face Flag:Yes or No
Contact Party: Collateral
Contact Type:Office or Telephone Made
Funding Source: Funding source of the Case Manager
Activities: Must check off all activities related to progress note
Brief Description:PCP Communication
Full Description: Must be a full description of encounter. SOAP or DAP outline may be used
- Other Type of Contact or Referral Service Provided
Definition: An internal or external referral to a service that meets the clinical or supportive needs of the client. The referral may be mailed, faxed, submitted electronically or completed over the phone.
Provide Documentation:
Create Activity > Referral
Referring Person: Name of Case Manager
Referral Date: Must be the actual date that the referral was completed
Referred for Service Type: Select service from the drop down list
Press Submit
After a referral has been made, a case manager must state the outcome of the referral at a later date.
Outcome of the Referral
View > Activity > Referral > Double click on the submitted Referral > Edit
Disposition: Select the outcome from the drop down list
Press Close