Common use of Assessment and Member-Centered Care Planning Clause in Contracts

Assessment and Member-Centered Care Planning. The Contractor shall ensure that certain Enrollees, as described in this Section and further specified by EOHHS, are comprehensively assessed and receive a documented Care Plan that is informed by such assessment. Such assessment and documented Care Plan shall be member- centered and shall inform Enrollees’ care, including but not limited to any Care Management activities, as described in this Section and further specified by EOHHS. 1. The Contractor shall comprehensively assess certain Enrollees as follows: a. The Contractor shall, either directly or, as appropriate, through its Community Partners, at a minimum, comprehensively assess: 1) LTSS CP-Assigned Enrollees; 2) BH CP-Assigned Enrollees. For any such BH CP-Assigned Enrollees, the Contractor shall obligate the Contractor’s BH CPs to comprehensively assess such Enrollees; and 3) Enrollees with Special Health Care Needs; b. The Contractor shall ensure that Enrollees are comprehensively assessed using a person-centered assessment of an Enrollee’s care needs and, as applicable and clinically appropriate, the Enrollee’s functional needs, accessibility needs, goals, and other characteristics, taking into consideration the domains listed in Section 2.3.D.1.l; c. The Contractor shall ensure such Comprehensive Assessments are completed within 90 days of each such Enrollee’s assignment to a BH or LTSS CP; d. The Contractor shall ensure that Enrollees with Special Health Care Needs are comprehensively assessed within 180 days of their enrollment date in Contract Year 1, and the Contractor shall ensure that new Enrollees with Special Health Care Needs enrolled in each subsequent year are comprehensively assessed within 90 days of enrollment; e. The Contractor shall update such assessments at least annually thereafter, and whenever an Enrollee experiences a major change in more than one area of health status that is not temporary or episodic, and requires interdisciplinary review or revision of the Enrollee’s Care Plan; f. The Contractor shall record such assessments in Enrollees’ health record; g. Such assessments shall be performed using assessment tools and methods as approved by EOHHS; h. The Contractor shall ensure that such assessments are completed independently, by an individual who is not financially or otherwise conflicted, as further defined by EOHHS; i. The Contractor shall respond to requests by EOHHS or EOHSS’ designee (e.g., EOHHS’ Third Party Administrator (TPA)) for copies of the assessments of Enrollees seeking Long-Term Services and Supports as follows and as further specified by EOHHS; 1) For such an Enrollee for whom such assessment has been completed, the Contractor shall provide a copy of such assessment as specified by EOHHS; 2) For such an Enrollee for whom no such assessment has been completed, the Contractor shall provide the Enrollee’s Care Needs Screening information or other information as specified by EOHHS. 3) The Contractor shall designate an individual to receive such requests and shall supply contact information for that individual to EOHHS. j. As further directed by EOHHS, the Contractor may, where appropriate, meet the assessment requirement, as described in Section 2.3.D, with an existing assessment for an Enrollee rather than conducting a new assessment, where such existing assessment is timely and appropriate, as further defined by EOHHS; k. As requested by EOHHS, the Contractor shall report, in a form and format as specified by EOHHS, about such assessments in accordance with Appendix F; l. Comprehensive Assessments for BH and LTSS CP-Assigned Enrollees 1) The Contractor shall provide, either directly or, as appropriate through its Community Partners, a Comprehensive Assessment, as further specified by EOHHS, to LTSS CP-Assigned Enrollees and BH CP-Assigned Enrollees; 2) Comprehensive Assessments, as provided to BH and LTSS CP-Assigned Enrollees, shall include domains and considerations appropriate for the population receiving the Comprehensive Assessment, as further specified by EOHHS, and may include, but may not be limited to, the following domains and considerations, as they relate to the Enrollee: a) Immediate care needs and current services, including but not limited to any care coordination or management activities and any services activities being provided by state agencies such as DMH, DDS, MRC, MCB, DCF, DYS, or EOEA; b) Health conditions; c) Medications; d) Ability to communicate their concerns, symptoms, or care goals; e) Functional status, including needs for assistance with any Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs); f) Self-identified strengths, weaknesses, interests, choices, care goals, and personal goals; g) Current and past mental health needs and substance use; h) Accessibility requirements, including but not limited to preferred language and specific communication needs, transportation needs, and equipment needs; i) Housing and home environment, including but not limited to risk of homelessness, housing preferences, and safety; j) Employment status, interests, and goals, as well as current use of and goals for leisure time; k) Available informal, caregiver, or social supports, including peer supports; l) Risk factors for abuse or neglect; m) Food security, nutrition, wellness, and exercise; n) Advance directives status and preferences and guardianship status; and o) Other domains and considerations identified by EOHHS. 3) EOHHS may specify such Comprehensive Assessment tool, at EOHHS’ discretion; 4) Such Comprehensive Assessments shall be appropriate to the Enrollee, shall be Enrollee-centered, and shall take place in a location that meets the Enrollee’s needs, including home-based assessments as appropriate; 5) Such Comprehensive Assessments shall incorporate an assessment of the Enrollee’s functional needs for LTSS, as further specified by EOHHS; 2. The Contractor shall provide Enrollees with documented Care Plans as follows: a. The Contractor shall, at a minimum, provide, either directly or, as appropriate, through its Community Partners, documented Care Plans to: 1) LTSS CP-Assigned Enrollees; 2) BH CP-Assigned Enrollees. For any such BH CP-Assigned Enrollees, the Contractor shall obligate the Contractor’s BH CPs to provide such Care Plans; and 3) Enrollees with Special Health Care Needs; b. As requested by EOHHS, the Contractor shall report, in a form and format as specified by EOHHS, about Care Plans in accordance with Appendix A; c. Such Care Plans shall: 1) Be based on an Enrollee’s Comprehensive Assessment, or other approved assessment as described in Section 2.3.D.1, and developed under the direction of the Enrollee (or the Enrollee’s representative, if applicable); 2) Reflect the Enrollee’s preference and needs; 3) Be updated periodically to reflect changes in the Enrollee’s needs, health status, or course of treatment. The Enrollee shall be at the center of the care planning process; 4) Designate the Enrollee’s care team, as applicable, including participants of the Enrollee’s choosing; 5) Be signed or otherwise approved by the Enrollee. The Contractor shall establish and maintain policies and procedures to ensure an Enrollee can sign or otherwise convey approval of his or her Care Plan when it is developed or subsequently modified. Such policies and procedures shall include: d. Informing an Enrollee of his or her right to approve the Care Plan; e. Providing the Enrollee with a copy of the Care Plan; and f. Providing mechanisms for the Enrollee to sign or otherwise convey approval of the Care Plan. Such mechanisms shall meet the Enrollee’s accessibility needs.

Assessment and Member-Centered Care Planning. The Contractor shall ensure that certain Enrollees, as described in this Section and further specified by EOHHS, are comprehensively assessed and receive a documented Care Plan that is informed by such assessment. Such assessment and documented Care Plan shall be member- member-centered and shall inform Enrollees’ care, including but not limited to any Care Management activities, as described in this Section and further specified by EOHHS. 1. The Contractor shall comprehensively assess certain Enrollees as follows: a. The Contractor shall, either directly or, as appropriate, through its Community Partners, at a minimum, comprehensively assess: 1) LTSS CP-Assigned Enrollees; 2) BH CP-Assigned Enrollees. For any such BH CP-Assigned Enrollees, the Contractor shall obligate the Contractor’s BH CPs to comprehensively assess such Enrollees; and 3) Enrollees with Special Health Care Needs; b. The Contractor shall ensure that Enrollees are comprehensively assessed using a person-centered assessment of an Enrollee’s care needs and, as applicable and clinically appropriate, the Enrollee’s functional needs, accessibility needs, goals, and other characteristics, taking into consideration the domains listed in Section 2.3.D.1.l; c. The Contractor shall ensure such Comprehensive Assessments are completed within 90 days of each such Enrollee’s assignment to a BH or LTSS CP; d. The Contractor shall ensure that Enrollees with Special Health Care Needs are comprehensively assessed within 180 days of their enrollment date in Contract Year 1, and the Contractor shall ensure that new Enrollees with Special Health Care Needs enrolled in each subsequent year are comprehensively assessed within 90 days of enrollment; e. The Contractor shall update such assessments at least annually thereafter, and whenever an Enrollee experiences a major change in more than one area of health status that is not temporary or episodic, and requires interdisciplinary review or revision of the Enrollee’s Care Plan; f. The Contractor shall record such assessments in Enrollees’ health record; g. Such assessments shall be performed using assessment tools and methods as approved by EOHHS; h. The Contractor shall ensure that such assessments are completed independently, by an individual who is not financially or otherwise conflicted, as further defined by EOHHS; i. The Contractor shall respond to requests by EOHHS or EOHSS’ designee (e.g., EOHHS’ Third Party Administrator (TPA)) for copies of the assessments of Enrollees seeking Long-Term Services and Supports as follows and as further specified by EOHHS; 1) For such an Enrollee for whom such assessment has been completed, the Contractor shall provide a copy of such assessment as specified by EOHHS; 2) For such an Enrollee for whom no such assessment has been completed, the Contractor shall provide the Enrollee’s Care Needs Screening information or other information as specified by EOHHS. 3) The Contractor shall designate an individual to receive such requests and shall supply contact information for that individual to EOHHS. j. As x. Xx further directed by EOHHS, the Contractor may, where appropriate, meet the assessment requirement, as described in Section 2.3.D, with an existing assessment for an Enrollee rather than conducting a new assessment, where such existing assessment is timely and appropriate, as further defined by EOHHS; k. As x. Xx requested by EOHHS, the Contractor shall report, in a form and format as specified by EOHHS, about such assessments in accordance with Appendix F; l. Comprehensive Assessments for BH and LTSS CP-Assigned Enrollees 1) The Contractor shall provide, either directly or, as appropriate through its Community Partners, a Comprehensive Assessment, as further specified by EOHHS, to LTSS CP-Assigned Enrollees and BH CP-Assigned Enrollees; 2) Comprehensive Assessments, as provided to BH and LTSS CP-Assigned Enrollees, shall include domains and considerations appropriate for the population receiving the Comprehensive Assessment, as further specified by EOHHS, and may include, but may not be limited to, the following domains and considerations, as they relate to the Enrollee: a) Immediate care needs and current services, including but not limited to any care coordination or management activities and any services activities being provided by state agencies such as DMH, DDS, MRC, MCB, DCF, DYS, or EOEA; b) Health conditions; c) Medications; d) Ability to communicate their concerns, symptoms, or care goals; e) Functional status, including needs for assistance with any Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs); f) Self-identified strengths, weaknesses, interests, choices, care goals, and personal goals; g) Current and past mental health needs and substance use; h) Accessibility requirements, including but not limited to preferred language and specific communication needs, transportation needs, and equipment needs; i) Housing and home environment, including but not limited to risk of homelessness, housing preferences, and safety; j) Employment status, interests, and goals, as well as current use of and goals for leisure time; k) Available informal, caregiver, or social supports, including peer supports; l) Risk factors for abuse or neglect; m) Food security, nutrition, wellness, and exercise; n) Advance directives status and preferences and guardianship status; and o) Other domains and considerations identified by EOHHS. 3) EOHHS may specify such Comprehensive Assessment tool, at EOHHS’ discretion; 4) Such Comprehensive Assessments shall be appropriate to the Enrollee, shall be Enrollee-centered, and shall take place in a location that meets the Enrollee’s needs, including home-based assessments as appropriate; 5) Such Comprehensive Assessments shall incorporate an assessment of the Enrollee’s functional needs for LTSS, as further specified by EOHHS; 2. The Contractor shall provide Enrollees with documented Care Plans as follows: a. The Contractor shall, at a minimum, provide, either directly or, as appropriate, through its Community Partners, documented Care Plans to: 1) LTSS CP-Assigned Enrollees; 2) BH CP-Assigned Enrollees. For any such BH CP-Assigned Enrollees, the Contractor shall obligate the Contractor’s BH CPs to provide such Care Plans; and 3) Enrollees with Special Health Care Needs; b. As x. Xx requested by EOHHS, the Contractor shall report, in a form and format as specified by EOHHS, about Care Plans in accordance with Appendix A; c. Such Care Plans shall: 1) Be based on an Enrollee’s Comprehensive Assessment, or other approved assessment as described in Section 2.3.D.1, and developed under the direction of the Enrollee (or the Enrollee’s representative, if applicable); 2) Reflect the Enrollee’s preference and needs; 3) Be updated periodically to reflect changes in the Enrollee’s needs, health status, or course of treatment. The Enrollee shall be at the center of the care planning process; 4) Designate the Enrollee’s care team, as applicable, including participants of the Enrollee’s choosing; 5) Be signed or otherwise approved by the Enrollee. The Contractor shall establish and maintain policies and procedures to ensure an Enrollee can sign or otherwise convey approval of his or her Care Plan when it is developed or subsequently modified. Such policies and procedures shall include: d. Informing an Enrollee of his or her right to approve the Care Plan; e. Providing the Enrollee with a copy of the Care Plan; and f. Providing mechanisms for the Enrollee to sign or otherwise convey approval of the Care Plan. Such mechanisms shall meet the Enrollee’s accessibility needs.

Assessment and Member-Centered Care Planning. The Contractor shall ensure that certain Enrollees, as described in this Section and further specified by EOHHS, are comprehensively assessed and receive a documented Care Plan that is informed by such assessment. Such assessment and documented Care Plan shall be member- centered and shall inform Enrollees’ care, including but not limited to any Care Management activities, as described in this Section and further specified by EOHHS. 1. The Contractor shall comprehensively assess certain Enrollees as follows: a. The Contractor shall, either directly or, as appropriate, through its Community Partners, at a minimum, comprehensively assess: 1) LTSS CP-Assigned Enrollees; 2) BH CP-Assigned Enrollees. For any such BH CP-Assigned Enrollees, the Contractor shall obligate the Contractor’s BH CPs to comprehensively assess such Enrollees; and 3) Enrollees with Special Health Care Needs; b. The Contractor shall ensure that Enrollees are comprehensively assessed using a person-centered assessment of an Enrollee’s care needs and, as applicable and clinically appropriate, the Enrollee’s functional needs, accessibility needs, goals, and other characteristics, taking into consideration the domains listed in Section 2.3.D.1.l; c. The Contractor shall ensure such Comprehensive Assessments are completed within 90 days of the effective date of each such Enrollee’s assignment to a BH or LTSS CP; d. The Contractor shall ensure that Enrollees with Special Health Care Needs are comprehensively assessed within 180 days of their enrollment date in Contract Year 1, and the Contractor shall ensure that new Enrollees with Special Health Care Needs enrolled in each subsequent year are comprehensively assessed within 90 days of enrollment; e. The Contractor shall update such assessments at least annually thereafter, and whenever an Enrollee experiences a major change in health status that is due to progressive disease, functional decline, or resolution of a problem or condition that represents a consistent pattern of changes that is not self-limiting; impacts more than one area of health status that is not temporary or episodic, and requires interdisciplinary review or revision of the Enrollee’s Care Planhealth status; and requires a review by the Enrollee’s care team; f. The Contractor shall record such assessments in Enrollees’ health medical record; g. Such assessments shall be performed using assessment tools and methods as approved by EOHHS; h. The Contractor shall ensure that such assessments are completed independently, by an individual who is not financially or otherwise conflicted, as further defined by EOHHS; i. The Contractor shall respond to requests by EOHHS or EOHSS’ designee (e.g., EOHHS’ Third Party Administrator (TPA)) for copies of the assessments of Enrollees seeking Long-Term Services and Supports as follows and as further specified by EOHHS; 1) For such an Enrollee for whom such assessment has been completed, the Contractor shall provide a copy of such assessment as specified by EOHHS; 2) For such an Enrollee for whom no such assessment has been completed, the Contractor shall provide the Enrollee’s Care Needs Screening information or other information as specified by EOHHS. 3) The Contractor shall designate an individual to receive such requests and shall supply contact information for that individual to EOHHS. j. As further directed by EOHHS, the Contractor may, where appropriate, meet the assessment requirement, as described in Section 2.3.D, with an existing assessment for an Enrollee rather than conducting a new assessment, where such existing assessment is timely and appropriate, as further defined by EOHHS; k. As requested by EOHHS, the Contractor shall report, in a form and format as specified by EOHHS, about such assessments in accordance with Appendix F; l. Comprehensive Assessments for BH and LTSS CP-Assigned Enrollees 1) The Contractor shall provide, either directly or, as appropriate through its Community Partners, a Comprehensive Assessment, as further specified by EOHHS, to LTSS CP-Assigned Enrollees and BH CP-Assigned Enrollees; 2) Comprehensive Assessments, as provided to BH and LTSS CP-Assigned Enrollees, shall include domains and considerations appropriate for the population receiving the Comprehensive Assessment, as further specified by EOHHS, and may shall include, but may not be limited to, the following domains and considerations, as they relate to the Enrollee: a) Immediate care needs and current services, including but not limited to any care coordination or management activities and any services activities being provided by state agencies such as DMH, DDS, MRC, MCB, DCF, DYS, or EOEA; b) Health conditions; c) Medications; d) Ability to communicate their concerns, symptoms, or care goals; e) Functional status, including needs for assistance with any Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs); f) Self-identified strengths, weaknesses, interests, choices, care goals, and personal goals; g) Current and past mental health needs and substance use; h) Accessibility requirements, including but not limited to preferred language and specific communication needs, transportation needs, and equipment needs; i) Housing and home environment, including but not limited to risk of homelessness, housing preferences, and safety; j) Employment status, interests, and goals, as well as current use of and goals for leisure time; k) Available informal, caregiver, or social supports, including peer supports; l) Risk factors for abuse or neglect; m) Food security, nutrition, wellness, and exercise; n) Advance directives status and preferences and guardianship status; and o) Other domains and considerations identified by EOHHS. 3) EOHHS may specify such Comprehensive Assessment tool, at EOHHS’ discretion; 4) Such Comprehensive Assessments shall be appropriate to the Enrollee, shall be Enrollee-centered, and shall take place in a location that meets the Enrollee’s needs, including home-based assessments as appropriate; 5) Such Comprehensive Assessments shall incorporate an assessment of the Enrollee’s functional needs for LTSS, as further specified by EOHHS; 2. The Contractor shall provide Enrollees with documented Care Plans as follows: a. The Contractor shall, at a minimum, provide, either directly or, as appropriate, through its Community Partners, documented Care Plans to: 1) LTSS CP-Assigned Enrollees; 2) BH CP-Assigned Enrollees. For any such BH CP-Assigned Enrollees, the Contractor shall obligate the Contractor’s BH CPs to provide such Care Plans; and 36) Enrollees with Special Health Care Needs; b. As requested by EOHHSUnless clinically appropriate, a new Comprehensive Assessment shall not be conducted for an Enrollee when a Comprehensive Assessment has been conducted for that Enrollee within the Contractor shall report, in a form last year and format as specified by EOHHS, about Care Plans in accordance with Appendix A; c. Such Care Plans shall: 1) Be based on an Enrollee’s Comprehensive Assessment, or other approved assessment as includes all domains and considerations described in Section 2.3.D.1, and developed under the direction of the Enrollee (or the Enrollee’s representative, if applicable); 2) Reflect the Enrollee’s preference and needs; 3) Be updated periodically to reflect changes in the Enrollee’s needs, health status, or course of treatment. The Enrollee shall be at the center of the care planning process; 4) Designate the Enrollee’s care team, as applicable, including participants of the Enrollee’s choosing; 5) Be signed or otherwise approved by the Enrollee. The Contractor shall establish and maintain policies and procedures to ensure an Enrollee can sign or otherwise convey approval of his or her Care Plan when it is developed or subsequently modified. Such policies and procedures shall include: d. Informing an Enrollee of his or her right to approve the Care Plan; e. Providing the Enrollee with a copy of the Care Plan; and f. Providing mechanisms for the Enrollee to sign or otherwise convey approval of the Care Plan. Such mechanisms shall meet the Enrollee’s accessibility needs.