Common use of Care Coordination Clause in Contracts

Care Coordination. The Contractor shall offer care coordination and case management services to all Enrollees, as described in Welfare and Institutions Code sections 14182.17(d)(4) and 14186(b). 2.5.2.1. Contractor will coordinate Enrollee care across the full continuum of service providers, including medical, Behavioral Health, and LTSS. 2.5.2.2. Contractor will focus on providing services in the least restrictive setting. 2.5.2.3. Care coordination will be led by the Care Coordinator with participation by members of the ICT. 2.5.2.4. Contractor shall ensure effective linkages of clinical and management systems among Network Providers. Such linkages shall be established in plan policies and procedures. 2.5.2.4.1. Such linkages shall include communication protocols among First Tier, Downstream, and Related Entities. 2.5.2.5. Contractor’s policies and procedures shall clarify all communications and reporting protocols related to coordination of services including but not limited to how Contractor shall oversee all such coordination activities. 2.5.2.6. Contractor will ensure that care coordination services: 2.5.2.6.1. Reflect a person-centered, outcome-based approach, consistent with the, CFAM-MOU, and DHCS’ RFS;Follow Enrollee’s direction about the level of involvement of his or her caregivers or medical providers; 2.5.2.6.2. Span medical and LTSS systems, including coordination with IHSS, with a focus on transitions; 2.5.2.6.3. Reflect coordination with county agencies and direct contractors, if applicable, for Behavioral Health services; 2.5.2.6.4. Reflect coordination with county agencies, if applicable, for IHSS services; 2.5.2.6.5. Include development of Individual Care Plans (ICP) with Enrollees, as described in Section 2.8.3; 2.5.2.6.6. Are performed by nurses, social workers, primary care providers, if appropriate, other medical, Behavioral Health, or LTSS professionals, and health plan care coordinators, as applicable; and 2.5.2.6.7. Reflect access to appropriate community resources, as defined in Welfare and Institution Code sections 14132.275(f)(7) and 14182.17(d) (4)(G) and (6)(B) and monitoring of skilled nursing utilization, with a focus on providing services in the least restrictive setting and transitions between the facilities and community. 2.5.2.7. Contractor will have a process for assigning a Care Coordinator to each Enrollee. Assignment will be made to a Care Coordinator with the appropriate experience and qualifications based on an Enrollee’s assigned risk level and individual needs. 2.5.2.7.1. Contractor shall ensure an adequate ratio of Care Coordinators to Enrollees to provide Care Coordination as required through this Contract. The CMT shall monitor the ratio of Care Coordinators to Enrollees on a regular basis. 2.5.2.8. Interdisciplinary Care Team (ICT). The Contractor shall offer an ICT for each Enrollee, which will be developed around the Enrollee and ensure the integration of the Enrollee’s medical and LTSS and the coordination of Behavioral Health Services delivered by a county Behavioral Health agency and IHSS services, when applicable. 2.5.2.8.1. Every Enrollee will have access to an ICT. 2.5.2.8.2. ICT Functions. ICT will facilitate care management, including assessment, care planning, and authorization of services, transitional care issues and work closely with providers listed in Section 2.5.

Care Coordination. The Contractor shall offer care coordination Care Coordination and case management services to all Enrollees, as described in Welfare and Institutions Code sections 14182.17(d)(4) and 14186(b). 2.5.2.1. Contractor will coordinate Enrollee care across the full continuum of service providers, including medical, Behavioral Health, and LTSS. 2.5.2.2. Contractor will focus on providing services in the least restrictive setting. 2.5.2.3. Care coordination Coordination will be led by the Care Coordinator with participation by members of the ICT. 2.5.2.4. Contractor shall ensure effective linkages of clinical and management systems among Network Providers. Such linkages shall be established in plan policies and procedures. 2.5.2.4.1. Such linkages shall include communication protocols among First Tier, Downstream, and Related Entities. 2.5.2.5. Contractor’s policies and procedures shall clarify all communications and reporting protocols related to coordination of services including but not limited to how Contractor shall oversee all such coordination activities. 2.5.2.6. Contractor will ensure that care coordination Care Coordination services: 2.5.2.6.1. Reflect a person-centered, outcome-based approach, consistent with the, CFAM-MOU, and DHCS’ RFS;Follow RFS; 2.5.2.6.2. Follow Enrollee’s direction about the level of involvement of his or her caregivers or medical providers; 2.5.2.6.22.5.2.6.3. Span medical and LTSS systems, including coordination with IHSS, with a focus on transitions; 2.5.2.6.32.5.2.6.4. Reflect coordination with county agencies and direct contractors, if applicable, for Behavioral Health services; 2.5.2.6.42.5.2.6.5. Reflect coordination with county agencies, if applicable, for IHSS services; 2.5.2.6.52.5.2.6.6. Reflect coordination with Medi-Cal Dental and any MMP supplemental dental benefits, as applicable, for dental services; 2.5.2.6.7. Include development of Individual Care Plans (ICP) with Enrollees, as described in Section 2.8.3; 2.5.2.6.62.5.2.6.8. Are performed by nurses, social workers, primary care providersPrimary Care Providers, if appropriate, other medical, Behavioral Health, or LTSS professionals, and health plan care coordinatorsCare Coordinators, as applicable; and 2.5.2.6.72.5.2.6.9. Reflect access to appropriate community resources, as defined in Welfare and Institution Code sections 14132.275(f)(7) and 14182.17(d) (4)(G) and (6)(B) and monitoring of skilled nursing utilization, with a focus on providing services in the least restrictive setting and transitions between the facilities and community. 2.5.2.7. Contractor will have a process for assigning a Care Coordinator to each Enrollee. Assignment will be made to a Care Coordinator with the appropriate experience and qualifications based on an Enrollee’s assigned risk level and individual needs. 2.5.2.7.1. Contractor shall ensure an adequate ratio of Care Coordinators to Enrollees to provide Care Coordination as required through this Contract. The CMT shall monitor the ratio of Care Coordinators to Enrollees on a regular basis. 2.5.2.8. Interdisciplinary Care Team (ICT). The Contractor shall offer an ICT for each Enrollee, which will be developed around the Enrollee and ensure the integration of the Enrollee’s medical and LTSS and the coordination of Behavioral Health Services delivered by a county Behavioral Health agency and IHSS services, when applicable.Health 2.5.2.8.1. Every Enrollee will have access to an ICT. 2.5.2.8.2. Enrollees may request the exclusion of any ICT member. 2.5.2.8.3. Contractor must include information about the ICT and ICP in their new member welcome packets. 2.5.2.8.4. ICT Functions. ICT will facilitate care management, including assessment, care planning, and authorization of services, transitional care issues and work closely with providers listed in Section 2.5.

Care Coordination. The Contractor shall offer care coordination and case management services to all Enrollees, as described in Welfare and Institutions Code sections WIC Sections 14182.17(d)(4) and 14186(b). 2.5.2.12.5.1.1. Contractor will coordinate Enrollee care across the full continuum of service providers, including medical, Behavioral Health, and LTSS. 2.5.2.22.5.1.2. Contractor will focus on providing services in the least restrictive setting. 2.5.2.32.5.1.3. Care coordination will be led by the Care Coordinator with participation by members of the ICT. 2.5.2.42.5.1.4. Contractor shall ensure effective linkages of clinical and management systems among Network Providers. Such linkages shall be established in plan policies and procedures. 2.5.2.4.12.5.1.4.1. Such linkages shall include communication protocols among Subcontracted Health Plans and First Tier, Downstream, and Related Entities. 2.5.2.52.5.1.5. Contractor’s policies and procedures shall clarify all communications and reporting protocols related to coordination of services including but not limited to how Contractor shall oversee all such coordination activities. 2.5.2.62.5.1.6. Contractor will ensure that care coordination services: 2.5.2.6.12.5.1.6.1. Reflect a person-centered, outcome-based approach, consistent with thethe CMS model of care, CFAM-MOU, and DHCS’ RFS;Follow RFS; 2.5.1.6.2. Maintain an Enrollee’s right to self-direct his or her IHSS, in addition to the right to hire, fire, and manage the IHSS provider, as described in WIC, Section 12301.6; 2.5.1.6.3. Follow Xxxxxxxx’s direction about the level of involvement of his or her caregivers or medical providers; 2.5.2.6.22.5.1.6.4. Span medical and LTSS systems, including coordination with IHSS, with a focus on transitions; 2.5.2.6.32.5.1.6.5. Reflect coordination with county agencies and direct contractors, if applicable, for Behavioral Health services; 2.5.2.6.4. Reflect coordination with county agencies, if applicable, for IHSS services; 2.5.2.6.52.5.1.6.6. Include development of Individual Care Plans (ICP) with Enrollees, as described in Section 2.8.3; 2.5.2.6.62.5.1.6.7. Are performed by nurses, social workers, primary care providers, if appropriate, other medical, Behavioral Health, or LTSS professionals, and health plan care coordinators, as applicable; and 2.5.2.6.72.5.1.6.8. Reflect access to appropriate community resources, as defined in Welfare and Institution Code sections WIC Sections 14132.275(f)(7) and 14182.17(d) (4)(G) and (6)(B) and monitoring of skilled ofskilled nursing utilization, with a focus on providing services in the least restrictive setting and transitions between the facilities and community. 2.5.2.72.5.1.7. Contractor will have a process for assigning a Care Coordinator to each EnrolleeEnrollee needing or requesting one. Assignment will be made to a Care Coordinator with the appropriate experience and qualifications based on an Enrollee’s assigned risk level and individual needs. 2.5.2.7.1. Contractor shall ensure an adequate ratio of Care Coordinators to Enrollees to provide Care Coordination as required through this Contract. The CMT shall monitor the ratio of Care Coordinators to Enrollees on a regular basis. 2.5.2.82.5.1.8. Interdisciplinary Care Team (ICT). The Contractor shall offer an ICT for each Enrollee, as necessary, which will be developed around the Enrollee and ensure the integration of the Enrollee’s medical and LTSS and the coordination of Behavioral Health Services delivered by a county Behavioral Health agency and IHSS servicesagency, when applicable. 2.5.2.8.12.5.1.8.1. Every Enrollee will have access to an ICTICT if requested. 2.5.2.8.22.5.1.8.2. ICT Functions. ICT will facilitate care management, including assessment, care planning, and authorization of services, transitional care issues and work closely with providers listed in Section 2.52.5.1.8.

Care Coordination. The Contractor shall offer care coordination and case management services to all Enrollees, as described in Welfare and Institutions Code sections WIC Sections 14182.17(d)(4) and 14186(b). 2.5.2.12.5.1.1. Contractor will coordinate Enrollee care across the full continuum of service providers, including medical, Behavioral Health, and LTSS. 2.5.2.22.5.1.2. Contractor will focus on providing services in the least restrictive setting. 2.5.2.32.5.1.3. Care coordination will be led by the Care Coordinator with participation by members of the ICT. 2.5.2.42.5.1.4. Contractor shall ensure effective linkages of clinical and management systems among Network Providers. Such linkages shall be established in plan policies and procedures. 2.5.2.4.12.5.1.4.1. Such linkages shall include communication protocols among First Tier, Downstream, and Related Entities. 2.5.2.52.5.1.5. Contractor’s policies and procedures shall clarify all communications and reporting protocols related to coordination of services including but not limited to how Contractor shall oversee all such coordination activities. 2.5.2.62.5.1.6. Contractor will ensure that care coordination services: 2.5.2.6.12.5.1.6.1. Reflect a person-centered, outcome-based approach, consistent with thethe CMS model of care, CFAM-MOU, and DHCS’ RFS;Follow RFS; 2.5.1.6.2. Maintain an Enrollee’s right to self-direct his or her IHSS, in addition to the right to hire, fire, and manage the IHSS provider, as described in WIC, Section 12301.6; 2.5.1.6.3. Follow Xxxxxxxx’s direction about the level of involvement of his or her caregivers or medical providers; 2.5.2.6.22.5.1.6.4. Span medical and LTSS systems, including coordination with IHSS, with a focus on transitions; 2.5.2.6.32.5.1.6.5. Reflect coordination with county agencies and direct contractors, if applicable, for Behavioral Health services; 2.5.2.6.4. Reflect coordination with county agencies, if applicable, for IHSS services; 2.5.2.6.52.5.1.6.6. Include development of Individual Care Plans (ICP) with Enrollees, as described in Section 2.8.3; 2.5.2.6.62.5.1.6.7. Are performed by nurses, social workers, primary care providers, if appropriate, other medical, Behavioral Health, or LTSS professionals, and health plan care coordinators, as applicable; and 2.5.2.6.72.5.1.6.8. Reflect access to appropriate community resources, as defined in Welfare and Institution Code sections WIC Sections 14132.275(f)(7) and 14182.17(d) (4)(G) and (6)(B) and monitoring of skilled ofskilled nursing utilization, with a focus on providing services in the least restrictive setting and transitions between the facilities and community. 2.5.2.72.5.1.7. Contractor will have a process for assigning a Care Coordinator to each EnrolleeEnrollee needing or requesting one. Assignment will be made to a Care Coordinator with the appropriate experience and qualifications based on an Enrollee’s assigned risk level and individual needs. 2.5.2.7.1. Contractor shall ensure an adequate ratio of Care Coordinators to Enrollees to provide Care Coordination as required through this Contract. The CMT shall monitor the ratio of Care Coordinators to Enrollees on a regular basis. 2.5.2.82.5.1.8. Interdisciplinary Care Team (ICT). The Contractor shall offer an ICT for each Enrollee, as necessary, which will be developed around the Enrollee and ensure the integration of the Enrollee’s medical and LTSS and the coordination of Behavioral Health Services delivered by a county Behavioral Health agency and IHSS servicesagency, when applicable. 2.5.2.8.12.5.1.8.1. Every Enrollee will have access to an ICTICT if requested. 2.5.2.8.22.5.1.8.2. ICT Functions. ICT will facilitate care management, including assessment, care planning, and authorization of services, transitional care issues and work closely with providers listed in Section 2.5.

Care Coordination. The Contractor shall offer care coordination Care Coordination and case management services to all Enrollees, as described in Welfare and Institutions Code sections 14182.17(d)(4) and 14186(b). 2.5.2.1. Contractor will coordinate Enrollee care across the full continuum of service providers, including medical, Behavioral Health, and LTSS. 2.5.2.2. Contractor will focus on providing services in the least restrictive setting. 2.5.2.3. Care coordination Coordination will be led by the Care Coordinator with participation by members of the ICT. 2.5.2.4. Contractor shall ensure effective linkages of clinical and management systems among Network Providers. Such linkages shall be established in plan policies and procedures. 2.5.2.4.1. Such linkages shall include communication protocols among First Tier, Downstream, and Related Entities. 2.5.2.5. Contractor’s policies and procedures shall clarify all communications and reporting protocols related to coordination of services including but not limited to how Contractor shall oversee all such coordination activities. 2.5.2.6. Contractor will ensure that care coordination Care Coordination services: 2.5.2.6.1. Reflect a person-centered, outcome-based approach, consistent with the, CFAM-MOU, and DHCS’ RFS;Follow EnrolleeRFS; 2.5.2.6.2. Follow Xxxxxxxx’s direction about the level of involvement of his or her caregivers or medical providers; 2.5.2.6.22.5.2.6.3. Span medical and LTSS systems, including coordination with IHSS, with a focus on transitions; 2.5.2.6.32.5.2.6.4. Reflect coordination with county agencies and direct contractors, if applicable, for Behavioral Health services; 2.5.2.6.42.5.2.6.5. Reflect coordination with county agencies, if applicable, for IHSS services; 2.5.2.6.52.5.2.6.6. Reflect coordination with Medi-Cal Dental and any MMP supplemental dental benefits, as applicable, for dental services; 2.5.2.6.7. Include development of Individual Care Plans (ICP) with Enrollees, as described in Section 2.8.3; 2.5.2.6.62.5.2.6.8. Are performed by nurses, social workers, primary care providersPrimary Care Providers, if appropriate, other medical, Behavioral Health, or LTSS professionals, and health plan care coordinatorsCare Coordinators, as applicable; and 2.5.2.6.72.5.2.6.9. Reflect access to appropriate community resources, as defined in Welfare and Institution Code sections 14132.275(f)(7) and 14182.17(d) (4)(G) and (6)(B) and monitoring of skilled nursing utilization, with a focus on providing services in the least restrictive setting and transitions between the facilities and community. 2.5.2.7. Contractor will have a process for assigning a Care Coordinator to each Enrollee. Assignment will be made to a Care Coordinator with the appropriate experience and qualifications based on an Enrollee’s assigned risk level and individual needs. 2.5.2.7.1. Contractor shall ensure an adequate ratio of Care Coordinators to Enrollees to provide Care Coordination as required through this Contract. The CMT shall monitor the ratio of Care Coordinators to Enrollees on a regular basis. 2.5.2.8. Interdisciplinary Care Team (ICT). The Contractor shall offer an ICT for each Enrollee, which will be developed around the Enrollee and ensure the integration of the Enrollee’s medical and LTSS and the coordination of Behavioral Health Services delivered by a county Behavioral Health agency and IHSS services, when applicable. ICTs must be comprised of professionals appropriate for the needs, preferences, and abilities of the Enrollee. 2.5.2.8.1. Every Enrollee will have access to an ICT. 2.5.2.8.2. Enrollees may request the exclusion of any ICT member. 2.5.2.8.3. Contractor must include information about the ICT and ICP in their new member welcome packets. 2.5.2.8.4. ICT Functions. ICT will facilitate care management, including assessment, care planning, and authorization of services, transitional care issues and work closely with providers listed in Section 2.52.5.2.8.5.1 to stabilize medical conditions, increase compliance with Care Plans, maintain functional status, and meet individual Enrollees Care Plan goals. ICT functions will include, at a minimum: 2.5.2.8.4.1. Develop and implement an ICP with Enrollee and/or caregiver participation as further described in Sections 2.5.2.9 and 2.8.3; 2.5.2.8.4.2. Conduct ICT meetings periodically, including at the Enrollee's discretion; 2.5.2.8.4.3. Manage communication and information flow regarding referrals, transitions, and care delivered outside the primary care site; 2.5.2.8.4.4. Maintain a call line or other mechanism for Enrollee inquiries and input , and a process for referring to other agencies, such as LTSS, IHSS, or Behavioral Health agencies, as appropriate; 2.5.2.8.4.5. Conduct conference calls among the Contractor, providers, and Enrollees; 2.5.2.8.4.6. Maintain a mechanism for monitoring Enrollee complaints and Grievances; and 2.5.2.8.4.7. Use secure email, fax, web portals or written correspondence to communicate. The ICT must take the Enrollee's individual needs (e.g., communication, cognitive, or other barriers) into account in communicating with the Enrollee.

Care Coordination. The Contractor shall offer care coordination and case management services to all Enrollees, as described in Welfare and Institutions Code sections 14182.17(d)(4) and 14186(b).14186(b).‌ 2.5.2.12.5.1.1. Contractor will coordinate Enrollee care across the full continuum of service providers, including medical, Behavioral Health, and LTSS. 2.5.2.22.5.1.2. Contractor will focus on providing services in the least restrictive setting. 2.5.2.32.5.1.3. Care coordination will be led by the Care Coordinator with participation by members of the ICT. 2.5.2.42.5.1.4. Contractor shall ensure effective linkages of clinical and management systems among Network Providers. Such linkages shall be established in plan policies and procedures. 2.5.2.4.12.5.1.4.1. Such linkages shall include communication protocols among First Tier, Downstream, and Related Entities. 2.5.2.52.5.1.5. Contractor’s policies and procedures shall clarify all communications and reporting protocols related to coordination of services including but not limited to how Contractor shall oversee all such coordination activities. 2.5.2.62.5.1.6. Contractor will ensure that care coordination services: 2.5.2.6.12.5.1.6.1. Reflect a person-centered, outcome-based approach, consistent with thethe CMS model of care, CFAM-MOU, and DHCS’ RFS;Follow RFS; 2.5.1.6.2. Maintain an Enrollee’s right to self-direct his or her IHSS, in addition to the right to hire, fire, and manage the IHSS provider, as described in Welfare and Institutions Code , section 12301.6; 2.5.1.6.3. Follow Xxxxxxxx’s direction about the level of involvement of his or her caregivers or medical providers; 2.5.2.6.22.5.1.6.4. Span medical and LTSS systems, including coordination with IHSS, IHSS with a focus on transitions; 2.5.2.6.32.5.1.6.5. Reflect coordination with county agencies and direct contractors, if applicable, for Behavioral Health services; 2.5.2.6.4. Reflect coordination with county agencies, if applicable, for IHSS services; 2.5.2.6.52.5.1.6.6. Include development of Individual Care Plans (ICP) with Enrollees, as described in Section 2.8.3; 2.5.2.6.62.5.1.6.7. Are performed by nurses, social workers, primary care providers, if appropriate, other medical, Behavioral Health, or LTSS professionals, and health plan care coordinators, as applicable; and 2.5.2.6.72.5.1.6.8. Reflect access to appropriate community resources, as defined in Welfare and Institution Code sections 14132.275(f)(7) and 14182.17(d) (4)(G) and (6)(B) and monitoring of skilled nursing utilization, with a focus on providing services in the least restrictive setting and transitions between the facilities and community. 2.5.2.72.5.1.7. Contractor will have a process for assigning a Care Coordinator to each Enrollee. Assignment will be made to a Care Coordinator with the appropriate experience and qualifications based on an Enrollee’s assigned risk level and individual needs. 2.5.2.7.1. Contractor shall ensure an adequate ratio of Care Coordinators to Enrollees to provide Care Coordination as required through this Contract. The CMT shall monitor the ratio of Care Coordinators to Enrollees on a regular basis. 2.5.2.82.5.1.8. Interdisciplinary Care Team (ICT). The Contractor shall offer an ICT for each Enrollee, as necessary, which will be developed around the Enrollee and ensure the integration of the Enrollee’s medical and LTSS and the coordination of Behavioral Health Services delivered by a county Behavioral Health agency and IHSS services, when applicable.of 2.5.2.8.12.5.1.8.1. Every Enrollee will have access to an ICT. 2.5.2.8.22.5.1.8.2. ICT Functions. ICT will facilitate care management, including assessment, care planning, and authorization of services, transitional care issues and work closely with providers listed in Section 2.5.