Chapter 13 Case Management in Cornerstone

13.1 CASE MANAGEMENT SCREEN FLOW FOR ALL PARTICIPANTS
13.2 SCREEN FLOW FOR IMMUNIZATION PARTICIPANTS

13.1 CASE MANAGEMENT SCREEN FLOW FOR ALL PARTICIPANTS

Following is information about entry of data into the Cornerstone system for a participant in one of the following programs:

Adverse Pregnancy Outcomes Reporting System (APORS)
Closing the Gap (CTG)Family Case Management (FCM)
High Risk Infant Follow-Up (HRIF)
Healthy Start Case Management (HSCM)
Immunizations (IMM)
Pediatric Primary Care (PPC)
Prenatal (PREN)
Targeted Intensive Prenatal Case Management (TIP)

FCM NOTE: FCM includes DCFS Wards, Title 20 participants, APORS infants, and All Kids and Non-All Kids participants.

The participant should be referred to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) when appropriate.

IMM NOTE: Please refer to "13.2 Screen Flow for Immunization Participants" for more detailed information on immunization participants.

APORS and HRIF NOTES:

Cook County (CCDPH) sites will only be using the APOR Program and will no longer be using the Case Management (CM) Program.
At sites other than CCDPH, a participant must be active in Case Management (CM) to be entered into APOR or HRIF.
Participants may not be active in APOR or HRIF at more than one health department at a time.
Participants may be enrolled in either APOR (the participant has an Infant Discharge Record (IDR)) or they are HRIF (the participant does not have an IDR). To change a participant from one program to the other, the previous Program record must be terminated with a Term Reason of either '12 - Error' or '65 - Inappropriate Referrals'.
Participants in either APOR or HRIF will automatically terminate once they reach 25 months of age.
CCDPH sites will assign Case Managers to APOR. All other sites will still use the Case Management (CM) Program to assign Case Managers.

Please refer to the following screen flows displayed in Appendix A for this chapter. The Immunization program has its own screen flow, while the remaining programs use the screen flows for each particular category. Only the Family Case Management program uses the DCFS ward and APORS screen flows.

"Cornerstone Case Management Screen Flow - Infant or Child (FCM1)"
"Cornerstone Case Management Screen Flow - Guardian* of Case Management Child (*Does not apply to foster parent) (FCM2)"
"Cornerstone Case Management Screen Flow - Pregnant Woman (FCM3)"
"Cornerstone Case Management Screen Flow - DCFS Ward Infant or Child (DCFS1)"
"Cornerstone Case Management Screen Flow - Pregnant DCFS Ward (DCFS2)"
"Cornerstone Case Management Screen Flow - APORS Infant or Child for CCDPH Sites Only (APORS1)"
"Cornerstone Immunization Only Screen Flow - New and Pre-existing participants (IMM1)"

SEQUENCE OF SCREENS

When fast path keys are not available at the bottom of the screen, easy access to various screens is available by pressing the CTRL and F9 keys simultaneously. Please refer to Chapter 2 "System Environment" under "2.4.3 Other Features" for more information.

PARTICIPANT LOOK-UP (PA01)

Prior to registration into the Cornerstone system, the Participant Look-up is used to verify the existence of a participant ID number by searching to find a participant who may have previously been enrolled in Cornerstone.

The screen is used to copy minimal demographic information on a participant who is already enrolled in the Cornerstone system to the local computer files. A "copy-in" of this data is necessary prior to performing a shared data Wide Area Network (WAN) look-up.

Use of the Participant Look-up reduces duplicate entry of participants. For this reason, the Participant Look-up must be performed before a new participant can be enrolled into the Cornerstone system. Please refer to Chapter 3 "Participant Screens" under "3.1 Participant Look-up (PA01)" for more information.

For information about resolving duplicate participants in Cornerstone, please refer to Chapter 3 "Participant Screens" under "3.21 Participant Duplicate Browse (PA21)".

PARTICIPANT ENROLLMENT (PA03) - add/edit Address as needed

This screen is used to enroll a new participant into the Cornerstone system and to capture demographic information for a new or existing participant. If the participant is already enrolled in Cornerstone, this screen is used to view and update demographic information.

The Participant Enrollment screen (PA03) is completed only once for each participant participating in Cornerstone programs, but can be edited thereafter. participants may be made active in several programs from the same enrollment record.

The processing within this screen includes checking for duplicate enrollment; assigning a unique, permanent statewide participant ID number (when enrolling a participant for the first time in the Cornerstone system); assessing potential eligibility for Cornerstone programs; and recording a participant's date of death.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key. This will copy-in and add to the local data any additional information found in a statewide look-up.

From this screen, the "Address" pop-up window is used to record address and telephone information by pressing F9.

Please refer to Chapter 3 "Participant Screens" under "3.5 Participant Enrollment (PA03)" for more information.

FCM and HSCM GUARDIAN NOTES: The following information is in regards to an adult parent or guardian (participant category "G") of a case managed infant or child.

A guardian of a new Cornerstone infant or child who is eligible for case management should be enrolled into the Cornerstone system only after the first successful contact with the eligible participant.
A pregnant woman active in case management will automatically have her category changed to guardian ("G") if she is grouped with an infant or child and no longer pregnant.
The guardian's name (as the contact person) and address will be displayed automatically for the eligible infant or child in the HFS address type in the Address window on this screen. (It is entered by the All Kids import process.)

FCM DCFS WARD NOTE (including foster parent guidelines):

Each time a DCFS ward changes placement the address information must be updated for the DCFS ward under the ward's residence address ("R"). The foster parent's address and telephone information must be added or updated in the "Address" pop-up window of this screen by pressing F9. The foster parent's name should be entered in the "Contact Person" field at the bottom of the "Address" pop-up window.

NOTE: This is the only information required on the foster parents, since the foster parent of a DCFS ward is not the legal guardian of the ward.

PROGRAM INFORMATION (PA15)

The Program Information screen (PA15) is used to record program eligibility. The screen is used to enroll a participant in all programs and, when completed, determines eligibility for a program based on rules for household size, annual income, age, and category.

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.1 General Information and Enrollment" for more information.

FCM, HSCM, and TIP GUARDIAN NOTES: The following information is in regards to an adult parent or guardian (participant category "G") of a case managed infant or child.

Participant category "G" is not limited to a child's legal guardian. Most often, the person with category "G" will be one of the child's parents, usually the mother.
Foster parents are not enrolled in the FCM program at all, so a Program Information screen (PA15) should not be completed for them. (Please refer to the notes below regarding DCFS wards for how to proceed in recording information in Cornerstone about foster parents.)

FCM DCFS WARD NOTES: The following information is in regards to DCFS Ward category changes:

DCFS wards are given the category codes "CFSI" if they are 12 months of age or younger or "CFSC" if they are over the age of one year.
An adolescent ward (category "CFSC") who becomes pregnant will have to be re-categorized manually as "CFSP" (DCFS Ward Pregnant).
An adolescent ward who is pregnant (category "CFSP") will automatically be re-categorized as "CFSC" (DCFS Ward Child) after the pregnancy is ended -- i.e., after completion of the Postpartum Data (PA10) screen or the Birth Data (PA11) screen.
The infant born to a ward will not automatically be a ward. If the child born to a ward is eligible for Family Case Management, the infant should be enrolled in the program with a participant category of "I" (Infant).
If the infant born to a ward becomes a ward, he or she must be enrolled in the program with a category of "CFSI" (DCFS Ward Infant) or "CFSC" (DCFS Ward Child).

APORS and HRIF NOTES:

For APORS CCDPH Sites:

Use the Program Information (PA15) screen to record the data required to determine the participant's eligibility for the APORS Program. When completing the Program Information (PA15) screen for APORS, use the 'APOR' Program Code. Once the record is saved, the participant's status becomes APORS-E (APORS Eligible). To activate the participant, a Case Management activity record must be entered on the Activity Entry (SV02) screen. Follow the 'Cornerstone Case Management Screen Flow for APORS Infant or Child for CCDPH Sites Only - APORS1'.

For Health Departments (Non-CCDPH sites):

The participant must first be active in the Case Management (CM) Program in order to add an APOR or HRIF Program record.
A participant may not be active in HRIF or APOR at the same time.

APORS and HRIF TRANSFER NOTES:

When a local health department requests a Case Management (CM) transfer, the Program Information (PA15) screen will automatically add a transfer record on the APOR or HRIF record and both will transfer.
When a site that is not a health department requests a Case Management (CM) transfer, only the CM record will transfer. The site that the transfer is requested from will receive a message on their HSPR0404 report with 'NOTR - TERM HRIF/APOR NOT TRANSFERRED'. This is to indicate the APOR or HRIF record is no longer being followed by any clinic.
For a CCDPH site, APORs records can be transferred between CCDPH sites.

PARTICIPANT MED/INSURANCE (PA05)

This screen is used to record a participant's Medicare, Insurance and/or other types of insurance information. The user may add Medicare and Other Types of insurance information as it becomes known, but the user is not allowed to add, edit or delete Insurance (INS) records. When the user enters information, the record may be edited, deleted, and used for inquiry.

Please refer to Chapter 3 "Participant Screens" under "3.4.2 Participant Med/Insurance (PA05)" for more information.

VIEW PARTICIPANT ADDITIONAL ELIGIBILITY INFORMATION (PA42)

This screen is used to view a participant's All Kids < 200% (formerly Medicaid), All Kids Expansion, Cash and Food Stamp information and is updated daily through the All Kids Import Process. Please refer to Appendix F "All Kids Import Process" for more information.

NOTE: Children do not enter the Cornerstone system automatically via the daily All Kids import process. Only women and infants enter through this process.

FCM, HSCM, and TIP GUARDIAN NOTES: The following information is in regards to an adult parent or guardian (participant category "G") of a case managed infant or child.

During the All Kids import process:

If the guardian is not eligible for All Kids, the guardian's name will be displayed in the "Contact Name" field on the infant's HFS address record. When an agency receives a new infant through the All Kids import, a Participant Enrollment screen (PA03) must be completed for the guardian.
If the guardian is eligible for All Kids, the All Kids import process will automatically create a Participant Enrollment record (PA03), Program Information record (PA15), and View Participant Additional Eligibility Information record (PA42) for that adult. Minimal data (such as name, birth date, sex, race, Social Security number and pregnancy status) will be filled in automatically.

DCFS WARD INFORMATION (PA19) - only FCM DCFS Wards

This screen is used to record information about DCFS wards, including their case ID number, case worker, and the dates of various activities related to the provision of medical case management services.

When a ward in the local clinic's caseload is placed outside of the clinic's jurisdiction, the case must be closed by the transfer process. After the agency gets the message on the beginning of day (BOD) to terminate the participant, a transfer must be performed on the Program Information (PA15) screen to close the case.

The new case management agency receives the ward's Cornerstone records through the regular transfer process. (Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.4 In-State Transfers".)

NOTE: If the other agency is not on the Cornerstone system, it is necessary to close the case manually and mail a copy of the ward's records to the new agency.

Please refer to Chapter 3 "Participant Screens" under "3.11 DCFS Ward Information (PA19)" for more information.

PARTICIPANT GROUP RELATIONSHIPS (PA06) - as needed, but not FCM DCFS Wards or APORS participants at CCDPH sites

This screen is used to establish and display group relationships among participants in the Cornerstone system. To establish a group, all participants must be enrolled in Cornerstone (i.e., must have had the Participant Enrollment (PA03) screen completed).

The screen is used to add, update, end, or delete group relationships. The screen establishes family linkages necessary for Family Case Management program reporting (required for all FCM and Healthy Start families in order for the reports to accurately count families). The screen also establishes the group ID number to be used for WIC group food instrument (FI) issuance for a family. Group relationships are used when scheduling appointments with families.

GENERAL NOTES:

There must be at least one person with a category of "P" or "G" in the group.
All case managed infants and children must be grouped with an adult participant who is either category "P" or category "G".
The person given category "G" must be the Group Head. An infant can not be a Group Head.
Do not complete this screen for DCFS wards.

FCM DCFS WARD NOTE: DO NOT USE this screen to add the name of the foster parent for a DCFS ward. DCFS wards should not be put into group relationships. If a Cornerstone participant who is in an existing group becomes a DCFS ward, it will be necessary to terminate the group relationship for the ward.

Please refer to Chapter 3 "Participant Screens" under "3.8 Participant Group Relationships (PA06)" for more information.

HOUSEHOLD MEMBERS (PA16) - as needed, but not DCFS Wards

This screen is used to record the names and relationships of other members of the participant's household. This links household members who are not enrolled in Cornerstone to an existing participant. These household members need not be biologically or legally related to the participant. The screen should not be used to enter into a household those individuals who have been linked through a group relationship.

FCM DCFS WARD NOTE: Do not complete this screen for DCFS wards.

Please refer to Chapter 3 "Participant Screens" under "3.9 Household Members (PA16)" for more information.

CASELOAD REASSIGNMENT (AD17)

This screen is used by an administrator (supervisor) to assign newly enrolled (unassigned) participants who have a program record in the Breast and Cervical Cancer Program (BCCP), Family Case Management (FCM), Healthy Start Case Management (HSCM) and/or Early Intervention (EI) to a case manager.

This screen is used to change a participant's case manager and used to display a case manager's current caseload. Reassignment of a case manager's entire caseload to another case manager may be accomplished on this screen. Groups (families) can easily be assigned to the same case manager as well.

APORS and HRIF NOTE: CCDPH sites will assign Case Managers to APOR. All other sites will still use the Case Management program to assign Case Managers.

Please refer to Chapter 9 "Administrative Screens" under "9.6.6 Caseload Reassignment (AD17)" for more information.

GUARDIAN NOTE: At this point, if the participant/participant is a Guardian, then the next screen entered is the Assessment screen (AS01).

SERVICE ENTRY (SV01)

This screen is used for entering the actual services that have taken place for the specified participant, regardless of whether the services were delivered at the agency or by an external provider.

Case management requires that the following services be recorded on this screen:

DCFS Pregnant Ward Visits (802 - Prenatal Care)
Well Child Visits (806 - Well Child/EPSDT/Healthy Kids)
High Risk Infant Follow-up (907 - APORS Follow-up)

Other services can be recorded at the agency's discretion.

For each well child visit, medical information is entered on the Infant/Child Health Visit (PA09) screen. The Service Entry (SV01) screen must be completed as well, because performance on the well child visit outcome indicator is measured from this screen.

Please refer to Chapter 4 "Service/Activity Screens" under "4.1 Service Entry (SV01)" for more information.

WIC NOTE: All WIC services are recorded on this screen. (Please refer to Chapter 14 for the WIC (Special Supplemental Nutrition Program for Women, Infant, and Children) Process in Cornerstone.)

About Medical Screens

The appropriate medical screens may be completed as needed at this point. Because the medical screens are not program specific, they already may have been completed for the participant through another program in the agency and may not need to be done again

NOTE: In order to reduce duplication of data entry, medical screens should be completed before completing assessment screens. In many cases, this screen will be completed through the FCM program or through regular WIC visits for those women who are receiving WIC services in the case management agency.

FCM and HSCM PREGNANT WOMAN NOTE: The required medical screens for pregnant women in these programs are:

PA07 Initial Prenatal Data
PA08 Adult Health Visit
PA10 Postpartum Data
PA12 Immunizations or PA23 Multiple Immunization Entry (DCFS Wards only)

FCM and HSCM GUARDIAN NOTE: No medical screens are required for participant category "G" (guardian). Go to the Assessment (AS01) screen.

FCM (including APORS) and HSCM INFANTS/CHILDREN NOTE: The required medical screens for infants and children in these programs are:

PA09 Infant/Child Health Visit (recommended for DCFS Wards, but not required)
PA11 Birth Data (all children under age 2) - If completing for APORS infant, type "Y" for Yes in the "APORS" field
PA12 Immunizationsor PA23 Multiple Immunization Entry

IMMUNIZATION NOTE: The medical screens for Immunization participants are:

PA12 Immunizations
PA13 Immunization History (Review only)
PA14 Future Immunizations
PA23 Multiple Immunization Entry

INITIAL PRENATAL DATA (PA07)

This screen is used to add, update, or inquire about a participant's prenatal health visit information. This screen must be completed for all pregnant women. Only one record per pregnancy may be entered. If the Initial Prenatal Data (PA07) screen has already been completed for the current pregnancy, the user must edit this screen to fill in blank fields or to correct data in existing fields.

Please refer to Chapter 3 "Participant Screens" under "3.6.2 Initial Prenatal Data (PA07)" for more information.

ADULT HEALTH VISIT (PA08)

This screen is used to add, edit, or inquire upon medical/health visit information for an adult participant. The screen can be used to record information about visits made either to the Cornerstone clinic or to an outside provider. This screen is used for DCFS wards only if the participant is receiving clinical prenatal services.

Please refer to Chapter 3 "Participant Screens" under "3.8 Adult Health Visits (PA08)" for more information.

INFANT/CHILD HEALTH VISIT (PA09)

This screen is used to add, edit, or inquire about a participant's infant or child health visit information, regardless of the provider or the program in which the participant is enrolled. Information may be obtained from the parent, if the provider is an outside provider.

Please refer to Chapter 3 "Participant Screens" under "3.9 Infant/Child Health Visit (PA09)" for more information.

FCM DCFS WARDS NOTES:

Completion of this screen is required for all health visits for participants in category "CFSI".
Additionally, it is recommended that this screen be completed for past health visits. Information may be obtained from a variety of sources, including the foster parent, the DCFS case worker, and the health care provider.

POSTPARTUM DATA (PA10)

This screen is used to add, edit, or inquire about a participant's postpartum information. For each pregnancy, there must be one Initial Prenatal Data (PA07) screen and one Postpartum Data (PA10) screen completed. These screens are "linked" by certain information that is entered (for example, the "EDC Date" field).

Only one postpartum data record per pregnancy is allowed, even if the pregnancy results in a multiple birth. This screen must be completed within six weeks of delivery. Once a pregnancy has been "closed" through the completion of the Postpartum Data screen (PA10), some of the information on the Initial Prenatal Data (PA07) screen can not be edited.

Please refer to Chapter 3 "Participant Screens" under "3.10 Postpartum Data (PA10)" for more information.

BIRTH DATA (PA11)

This screen is used to record birth information for each infant or child. The Cornerstone system allows entry of only one birth record per participant. Use this screen to enter past birth information for DCFS wards, if available.

NOTE: This screen must be completed for all children participants under the age of 2.

Please refer to Chapter 3 "Participant Screens" under "3.11 Birth Data (PA11)" for more information.

IMMUNIZATION HISTORY (PA13)

This screen is used to inquire on the previous immunizations a participant has received in the local clinic. The screen shows Series 1 through 6, but only part of the data is visible on the screen. Use Tab or the left and right arrow keys to see the data not visible on the screen.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key, which will copy-in and add any statewide data to the local data.

When using this screen for a final review, the user can press F10 to print the Child Immunization Record (HSPR0301) as needed.

Please refer to Chapter 3 "Participant Screens" under "3.13 Immunization History (PA13)" for more information.

IMMUNIZATIONS (PA12)

This screen is used to enter current or past single immunizations for a participant by vaccine type, date, provider, lot number, and place of service. To enter multiple immunizations on a single participant when the same provider gave all of the immunizations on the same date, use the Multiple Immunization Entry (PA23) screen. (Please refer to Chapter 3 "Participant Screens" under "3.23 Multiple Immunization Entry (PA23)" for more information.)

The number in the series is automatically calculated. Infant, child, and adult immunizations can be recorded. Immunizations given by the local clinic, as well as those given by outside providers, may be recorded.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key, which will copy-in and add any statewide data to the local data.

Please refer to Chapter 3 "Participant Screens" under "3.6.6 Immunizations (PA12)" for more information.

FUTURE IMMUNIZATIONS (PA14)

This screen is used to inquire on recommended future immunizations, dose number in series, and recommended date for returning to receive vaccines. The Cornerstone system calculates this information based upon the recommendations of the Advisory Committee for Immunization Practices (ACIP).

Upon entering the screen, the user will have the option of retrieving shared data from the Wide Area Network (WAN), which will copy-in and add any statewide data to the local data or will use local data only.

Please refer to Chapter 3 "Participant Screens" under "3.14 Future Immunizations (PA14)" for more information.

MULTIPLE IMMUNIZATION ENTRY (PA23)

This screen is used to enter current or past multiple immunizations for the same participant at one time, rather than entering the immunizations individually using the Immunizations (PA12) screen. This screen allows greater flexibility in entering multiple immunizations on a single participant, when the same provider gave all of the immunizations on the same date. The number in the series is automatically calculated.

The screen can be used to inquire on prior immunizations, but can not be used to delete immunizations. The Immunizations (PA12) screen can be used for deletions. (Please refer to Chapter 3 "Participant Screens" under "3.12 Immunizations (PA12)" for more information.)

Infant, child, and adult immunizations can be recorded. Immunizations given by the local clinic, as well as those given by outside providers, may be recorded.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key, which will copy-in and add any statewide data to the local data.

Please refer to Chapter 3 "Participant Screens" under "3.23 Multiple Immunization Entry (PA23)" for more information.

ASSESSMENT (AS01)

This screen is used to record/assess the needs of all case managed participants for additional services by completing designated assessment types or to inquire on previously completed assessments. Assessments should be completed based upon MCH (maternal child health) rules and contract language.

The assessment process assists the health professional in developing an individual care plan that addresses the participant and their specific needs. The purpose of the assessments is to identify the strengths, weaknesses, problems, risk factors, or barriers to the participant's attainment of a specific goal or set of goals.

The Cornerstone system allows for multiple assessments of the same type to be given over time. The participant assessment responses will be kept historically in order to facilitate care plan development and case tracking.

The Assessment (AS01) screen is a feature of the Cornerstone system that is available for the use in all program areas.

Please refer to Chapter 7 "Assessment Screens" under "7.1 Assessment (AS01)" for more information.

NOTES:

The required assessments noted below must be completed within the number of days specified in the Family Case Management contract for the current fiscal year.
The participant's assigned case manager must complete the General Assessment (700).
The participant's case manager must complete the Home Assessment (706) during a home visit.
Other assessment types may be completed, based on the professional judgment of the case manager and local agency policy.
All questions should be addressed. If answers are unknown or do not apply, this should be indicated in the "Comments" box. The answer field can be left blank, allowing the user to move to the "Comments" box and type in the comment, as needed.
FCM Restructure Pilots only: There are three new risk screening assessments

711 - Prenatal Risk Screening

712 - Infant Risk Screening

713 - Child Risk Screening

At the end of each assessment, the participant's screening status will be evaluated depending on the answers to the questions that are marked with an asterisk (*).
- The preferred answer to all questions marked with an asterisk (*) is no (N), except for the question, "Do you have enough food to eat".
- Answering against the preferred to any of the questions marked with an asterisk (*) will automatically set the participant's screening value to 'AT RISK'.
At the end of the assessment is a question for the Case Manager (CM) to either agree or disagree.
- A response to this question is required before the assessment will save.
- If the CM agrees to the assessment and enters a 'Y', then the assessment can be saved.
- If the CM does not agree to the assessment and enters an 'N', the Employee ID (User currently logged into Cornerstone) and the current date will auto fill. Both of these fields are editable until questions that have an asterisk have been answered and saved.

FCM PREGNANT WOMAN NOTE: The following assessments are required for participant category "P" in the Family Case Management (FCM) program:

700 - General Assessment (questions 1-40)
701 - Other Service Barriers Assessment
706 - Home Assessment
707D - Prenatal Nutritional Assessment

NOTE: On the 707D - Prenatal Nutritional Assessment, question number 1 asks if the participant is receiving WIC services. If the answer to this question is yes, type in a "Y" and no further nutrition assessment questions need to be answered. If the participant is NOT receiving WIC services, all of the nutrition assessment questions should be completed.

711 Prenatal Risk Screening (For use by FCM restructuring sites only)

FCM GUARDIAN NOTE: The following assessments are required for the guardian in the Family Case Management (FCM) program:

700 - General Assessment (questions 1-40)
701 - Other Service Barriers Assessment
706 - Home Assessment

FCM INFANT/CHILD NOTES (including DCFS/APORS): The following assessments are required for each infant or child in the Family Case Management (FCM) program:

700 - General Assessment (questions 41-49)
708A-R - Anticipatory Guidance Assessment (complete the section as appropriate for age)
For infants who are not receiving WIC services, question number 82, regarding nutrition, on 708 - Pediatric Primary Case Assessment must be completed

The following assessment, in addition to the assessments above, is recommended for participant categories "CFSI" (DCFS Ward Infant) and "CFSC" (DCFS Ward Child):

708 - Pediatric Primary Care Assessment (Physical Exam: Questions 31-52; Lab Tests: Questions 59-69; and other appropriate data)

The following assessment, in addition to the assessments above, is required for an APORS infant:

708 - Pediatric Primary Care Assessment (Physical Exam: Questions 31-52; Nutrition Assessment: Questions 81-92; and other appropriate data)
712 - Infant Risk Screening (For use by FCM restructuring sites only) 12 months and under.
713 - Child Risk Screening (For use by FCM restructuring sites only) 13 months +

FCM PREGNANT DCFS WARD NOTES: The following assessments are required for participant category "CFSP" (DCFS Ward Pregnant):

700 - General Assessment (questions 1-12, 16-18, 21-26, and 41-49)
710 - Prenatal Education

The following assessments, in addition to the assessments above, are recommended for participant category "CFSP" (DCFS Ward Pregnant):

707A - Prenatal History
707B - Family Genetic History
707C - Past Medical History
707F - Laboratory Test

For DCFS wards, if the response is not known, leave it blank. Information can be obtained through DCFS, the schools, medical providers, and/or charts.

FCM TITLE 20 PREGNANT WOMAN NOTE: The following assessments are required for participant category "T20P" (Title 20 Pregnant Woman):

700 - General Assessment (questions 1-40)
701 - Other Service Barriers Assessment
706 - Home Assessment

HSCM PREGNANT WOMAN NOTE: The following assessments are required for participant category "P" (pregnant) in the Healthy Start program (HSCM):

700 - General Assessment
701 - Other Service Barriers Assessment
705 - Violence Assessment
706 - Home Assessment
707A - Prenatal History Assessment
707D - Prenatal Nutritional Assessment

HSCM GUARDIAN NOTE: The following assessments are required for participant category "G" (guardian) in the Healthy Start program (HSCM):

700 - General Assessment
701 - Other Service Barriers Assessment
705 - Violence Assessment
706 - Home Assessment

HSCM INFANT/CHILD NOTE: The following assessments are required for infants and children in the Healthy Start program (HSCM):

700 - General Assessment (questions 41-48)
706 - Home Assessment
708A-R - Anticipatory Guidance Assessment (complete the section as appropriate for age)

NOTE: For infants who are not receiving WIC services, question number 82, regarding nutrition, on 708 - Pediatric Primary Case Assessment must be completed.

TIP PREGNANT WOMAN NOTE: The following assessments are required for participant category "P" (pregnant) in the Targeted, Intensive Prenatal Case Management program (TIP):

700 - General Assessment (questions 1 - 40)
701 - Other Services Barrier Assessment
703 - Psychosocial Stress Assessment
704 - Alcohol/Substance Abuse Assessment
705 - Violence Assessment
706 - Home Assessment
707D - Prenatal Assessment
707G - Prenatal High Risk Assessment
708 - Pediatric Primary Care Assessment

CASE NOTES (CM04)

This screen is optional and may be used at any time.

This screen is used to enter and view case notes for participants that are related to a service or a case management activity. Specifically, it is used:

to document services provided by the case manager.
to provide a clear and concise explanation of services delivered and claimed on the Activity Entry (SV02) screen.

This screen is available for use in all Cornerstone programs. Case notes are available to other users in the local agency who have security access to this screen, unless the note is marked confidential. If marked "confidential", only the user who entered the case note and their supervisor will be able to view the notes.

The case notes must be written in a clear and focused manner. Notes are free-form and may be used to record information about the service or activity provided to the participant. There is no limit to the number of notes that may be entered.

NOTE:Once case notes have been saved they cannot be edited or deleted. If errors occur, new case notes must be entered in order to correct the errors.

Please refer to Chapter 6 "Case Management Screens" under "6.4 Case Notes (CM04)" for more information.

HSCM NOTE: Case Notes (CM04) must be used for Healthy Start program documentation.

PARTICIPANT GOALS (CM02) - edit as needed

This screen displays system-generated goals selected for the care plan, as well as a status and priority for each goal. The goals are generated as a result of the answers to assessment questions. The goals should be used as a guide in formulating the participant's individual care plan.

Goals may be added or changed from the standard list of goals, and the user may update goal detail information. Goals should not be deleted, per program policy. All goals should be addressed.

A minimum of one goal must be generated or developed for each participant. If all assessment questions were answered with the "norm", then no goals or services will be system-generated; therefore, the user will have to develop a goal.

Please refer to Chapter 6 "Case Management Screens" under "6.2 Participant Goals (CM02)" for steps on how to develop a goal and for more information.

FCM DCFS WARD NOTES:

For DCFS wards, the medical portion of the goals is the primary focus for medical case management.
Medical goals should be added, as appropriate.
If psychosocial goals have been generated, comments should be entered in the "Comments" box, indicating that psychosocial issues are being addressed by the DCFS case worker.

PLANNED SERVICES/CARE PLAN (CM03)

This screen displays system-generated services that are appropriate to the achievement of participant goals. As with goals, planned services are generated as a result of answers to assessment questions. Specifically, the screen is used:

To view the services recommended for a participant based upon the goals that have been generated from the answers to assessment questions.
To add or delete services as needed.
To update the status and/or the planned completion date for a service.

Additional information on participant planned services is as follows:

The planned services list only occurs as a result of conducting assessments. If the user adds to this list, it will be necessary to manually add services for the goals. Manually added goals and services will also be displayed on this screen.
The case manager must select at least one planned service for each goal established for the participant.
The order in which the services are to be addressed depends on the planned completion date.

Please refer to Chapter 6 "Case Management Screens" under "6.3 Planned Services/Care Plan (CM03)" for more information.

FCM DCFS WARD NOTES:

For DCFS wards, the medical portion of the planned services is the primary focus for medical case management.
Medical planned services should be added, as appropriate.
If psychosocial planned services have been generated, Case Notes (CM04) should be entered indicating that psychosocial issues are being addressed by the DCFS case worker. In this case, indicate that the status is "IP" (in progress).

SCHEDULE APPOINTMENT (SC02)

This screen is used regularly by all programs to record/schedule and maintain clinic appointments for participants. Dates and schedules are selected through the use of pop-up windowes.

The screen displays all of the appointments for the requested schedule and date. This information is displayed in a format of time slots and resources. Appointments may be added or deleted using this screen. The "Appointment Information" pop-up window displays the details of a particular appointment.

The time slots display down the left side of the screen. The resources are displayed across the top of the screen. Resources may be employees, exam rooms, or types of service(s). The resources are established on the Clinic Schedules (AD04) screen and are not tied to the employee ID that is displayed in the left corner of the "Appointment Information" pop-up window.

This screen also identifies the closed times for that schedule or for the clinic as established on the Schedule Closed Dates (AD19) screen.

Please refer to Chapter 5 "Scheduling and Referral Screens" under "5.2 Schedule Appointment (SC02)" for more information.

SERVICE PROVIDER SELECTION (RF01)

This screen is used to record/establish a referral for a participant to an outside provider for a specific type of service. Once a referral has been generated, certain information can be changed (appointment date/time and comments). When this screen is saved, the selected number of copies of the referral will be printed.

Please refer to Chapter 5 "Scheduling and Referral Screens" under "5.7 Service Provider Selection (RF01)" for more information.

HSPR0204 CARE PLAN (HSPR0204) and other reports as needed (RP01)

The RP01 screen is used to print all of the on-request reports. This report can be found at the Cornerstone Main Menu under Reports and under the Participant submenu.

Please refer to Chapter 11 "Reports" under "11.16 Care Plan (HSPR0204)" for more information about the specific report.

Step by Step Instructions

Press Ctrl+F1 to activate the Report Selection window. Press the down arrow three times to highlight "HSPR0204 Care Plan". Press Enter to select.
On the On-Request Report Selection screen (RP01), verify that the participant ID for which the report is to be printed is displayed in the "Grp/Part ID" field. If not, type in the ID number of the correct participant. (Please continue by following the Step by Step Instructions in Chapter 10 "Report Screens" under "10.1 On-Request Report Selection (RP01)", beginning with step 2.)

Other reports may also be printed, as necessary.

Please refer to Chapter 10 "Report Screens" for information on how to run a report.

Please refer to Chapter 11 "Reports" for more information about a specific report.

ACTIVITY ENTRY (SV02) - participant related

This screen is used by case management staff to enter participant-specific case management activities. Recording of time spent on case management activities is required in order to properly calculate the case management time involved with a participant. Activities that are not directly related to a specific participant are recorded on the Staff Time Entry (SV04) screen.

The screen is used in the Family Case Management program (FCM) to determine the costs to a local agency for performing case management activities for a family, and to determine that an agency is meeting specified performance requirements for timely case finding, frequency of face-to-face contact, and home visits with participants.

Agency case management staff identified as staff type "D" (direct service) are required to complete this screen during time study periods (the first two weeks of January, April, July and October). It is strongly encouraged that case managers complete this screen each day, not only during time study periods.

NOTE: Paper copies of the Time and Activity Logs, signed by the agency administrator, must be retained by the agency for a period of five years for HCFA (Health Care Financing Administration) auditing purposes. Requesting the Case Manager Activity Report (HSPR0723) will create paper copies. (Please refer to Chapter 11 "Reports" under "11.79 Case Manager Activity Report (HSPR0723)" for more information about this specific report.)

Please refer to Chapter 4 "Service/Activity Screens" under "4.3 Activity Entry (SV02)" for more information about this screen.

STAFF TIME ENTRY (SV04 ) - non-participant related

This screen is used for the Family Case Management program (FCM) by case management staff (by case managers, case manager assistants, and outreach workers) to record time spent on non-participant (non-case management) related activities.

The screen is used to record time spent on all activities other than case management. It is used to record time spent on outreach and time spent by case managers working in other programs (for example, WIC or Immunizations).

The screen displays both the non-participant related and participant related activities that have been recorded for the requested day. Use <Pg Up> and <Pg Dn> to scroll through past days.

Please refer to Chapter 4 "Service/Activity Screens" under "4.4 Staff Time Entry (SV04)" for more information.

13.2 SCREEN FLOW FOR IMMUNIZATION PARTICIPANTS

Please refer to the "Cornerstone Immunization Only Screen Flow - New and Pre-existing participants (IMM1)" screen flow displayed in Appendix A.

Following is information for entering appropriate data in Cornerstone for Immunization participants.

As of March 9, 2005 the Cornerstone Central Office nightly processing downloads new immunization records to the appropriate clinic site via the Beginning of Day process. There must be a Program information screen (PA15) in order for a participant to receive the new immunization record. This has eliminated the need to use the WAN to obtain immunization records. Any questions regarding immunizations and the WAN prior to this date should be addressed by calling the Cornerstone Service Desk.

SEQUENCE OF SCREENS

PARTICIPANT LOOK-UP (PA01)

Please refer to Chapter 3 "Participant Screens" under "3.1 Participant Look-up (PA01)" for more information.

For information about resolving duplicate participants in Cornerstone, please refer to Chapter 3 "Participant Screens" under "3.21 Participant Duplicate Browse (PA21)".

PARTICIPANT ENROLLMENT (PA03) - add/edit Address as needed

The Participant Enrollment (PA03) screen is completed only once for each participant participating in Cornerstone programs, but can be edited thereafter. participants may be made active in several programs from the same enrollment record.

From this screen, the "Address" pop-up window is used to record address and telephone information by pressing F9.

Please refer to Chapter 3 "Participant Screens" under "3.3 Participant Enrollment (PA03)" for more information.

PROGRAM INFORMATION (PA15)

The Program Information (PA15) screen is used to record program eligibility. The screen is used to enroll a participant in all programs and, when completed, determines eligibility for a program based on rules for household size, annual income, age, and category.

For the Immunization program, the Program Information (PA15) screen is used:

To enter information about an Immunization participant into Cornerstone. Immunization participants are tracked as active participants from this screen.
To record the fact that a participant has moved or "gone elsewhere" and to change the participant's status to "T - Terminated".

Immunization staff should not use this screen to request transfers of immunization participants. Immunization participants may be legitimately enrolled at multiple clinics. The WAN should be used to view all of a participant's immunization history, including immunizations given and recorded by another Cornerstone clinic.

To create an immunization record, use the "Program Type" code "IMM". Cornerstone will automatically select the "Category" of "V". Since there are no eligibility rules related to household size and income for the Immunizations program, entering an income amount is not required.

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.1 General Information and Enrollment" for more information.

SERVICE ENTRY (SV01)

This screen is used for entering the actual services that have taken place for the specified participant, regardless of whether the services were delivered at the agency or by an external provider.

For the Immunization program, the Service Entry (SV01) screen is used:

* To record immunization services received, past or present, that have been provided by either the clinic or a non-Cornerstone provider (i.e., a private physician).

This screen should not be used to record actual immunizations given.

When entering immunization services, the following service codes are used:

"ICG" for routine general immunization clinics and for any non-Cornerstone provider.
"IWCV" for immunizations given in conjunction with well child clinics.

Please refer to Chapter 4 "Service/Activity Screens" under "4.1 Service Entry (SV01)" for more information.

IMMUNIZATION HISTORY (PA13)

This screen is used to inquire on the previous immunizations a participant has received in the local clinic. The screen shows Series 1 through 6, but only part of the data are visible on the screen. Use Tab or the left and right arrow keys to see the data not visible on the screen.

This screen is for inquiry only; it cannot be used to record actual immunizations given.

When using this screen for a final review, the user can press F10 to print the Child Immunization Record (HSPR0301) as needed.

Please refer to Chapter 3 "Participant Screens" under "3.13 Immunization History (PA13)" for more information.

IMMUNIZATIONS (PA12)

This screen is used to enter current or past single immunizations for a participant by vaccine type, date, provider, lot number, and place of service. The Immunizations (PA12) screen can also be used to access previous immunization records from the shared data on the WAN. Immunization records that did not originate at the clinic will no longer be editable as of version 10.04 of Cornerstone. This includes Immunization Import records or records copied to the site through an F2 Share. The F7 - Delete function will still be available.

NOTE: To enter multiple immunizations on a single participant when the same provider gave all of the immunizations on the same date, use the Multiple Immunization Entry (PA23) screen. (Please refer to Chapter 3 "Participant Screens" under "3.23 Multiple Immunization Entry (PA23)" for more information.)

As of March 9, 2005 the Cornerstone Central Office nightly processing downloads new immunization records to the appropriate clinic site via the Beginning of Day process. There must be a Program information (PA15) screen in order for a participant to receive the new immunization record. This has eliminated the need to use the WAN to obtain immunization records. Any questions regarding immunizations and the WAN prior to this date should be addressed by calling the Cornerstone Service Desk.

An immunization code is required for every entry. Either the provider ID (for providers known to Cornerstone) or the provider name (for all other providers) must be entered. The "Comments" field may be used to record all documentation required for the Childhood Vaccine Inquiry Act.

This screen should not be used to enter immunization service codes. In addition, users can not add an immunization record if the immunization date is prior to the date the specified lot was received

Please refer to Chapter 3 "Participant Screens" under "3.12 Immunizations (PA12)" for more information.

FUTURE IMMUNIZATIONS (PA14)

Upon entering the screen, the user will have the option of retrieving shared data from the Wide Area Network (WAN) or will use local data only. This screen should not be used to inquire on previously given immunizations. Since it is an inquiry only screen, the Future Immunizations (PA14) screen can not be used to record actual immunizations given.

Please refer to Chapter 3 "Participant Screens" under "3.14 Future Immunizations (PA14)" for more information.

MULTIPLE IMMUNIZATION ENTRY (PA23)

The screen can be used to inquire on prior immunizations, but can not be used to delete immunizations. The Immunizations (PA12) screen can be used for deletions. (Please refer to Chapter 3 "Participant Screens" under "3.12 Immunizations (PA12)" for more information.)

Infant, child, and adult immunizations can be recorded. Immunizations given by the local clinic, as well as those given by outside providers, may be recorded.

As of March 9, 2005 the Cornerstone Central Office nightly processing downloads new immunization records to the appropriate clinic site via the Beginning of Day process. There must be a Program information (PA15) screen in order for a participant to receive the new immunization record. This has eliminated the need to use the WAN to obtain immunization records. Any questions regarding immunizations and the WAN prior to this date should be addressed by calling the Cornerstone Service Desk.

Users can not add an immunization record if the immunization date is prior to the date the specified lot was received

Please refer to Chapter 3 "Participant Screens" under "3.23 Multiple Immunization Entry (PA23)" for more information.

Chapter 13 Case Management in Cornerstone

Table of Contents

13.1 CASE MANAGEMENT SCREEN FLOW FOR ALL PARTICIPANTS

13.2 SCREEN FLOW FOR IMMUNIZATION PARTICIPANTS