Care Delivery Model. 2.5.1. Contractor shall abide by the care delivery model described within this Contract and is not required to submit a model of care to CMS or DHCS unless otherwise requested.
Care Delivery Model. Primary Care The PCP must:
1. Provide primary medical services, including acute and preventive care;
2. Refer the Enrollee, in coordination with the ICT and in accordance with the Contractor’s policies, to Covered Service providers, as medically appropriate; and
3. Lead the ICT, together with the Care Coordinator, and if indicated, with the behavioral health clinician.
Care Delivery Model. 2.5.1. The Contractor shall abide by the care delivery model described within this Contract and is not required to submit a model of care to CMS or RI EOHHS unless otherwise requested.
2.5.2. Person-centered System of Care The Contractor shall implement a person-centered system of care that governs the care provided to Enrollees and meets the following requirements:
2.5.2.1.1. Focuses on the individual, his or her strengths, and his or her network of Family and community supports;
2.5.2.1.2. Respects and responds to individual needs, goals and values;
2.5.2.1.3. Allows the Enrollee maximum choice and control over the supports he or she needs to live as independently as possible;
2.5.2.1.4. Works in full partnership with Enrollees and Health Care Professionals to guarantee that each person’s values, experiences, and knowledge drive the creation of an individual plan as well as the delivery of services;
2.5.2.1.5. Is built on the principle that Enrollees have rights and responsibilities, know their circumstances and needs first-hand, and should be invested in the care they receive;
2.5.2.1.6. Establishes a foundation for independence, self-reliance, self- management, and successful intervention outcomes;
2.5.2.1.7. Crafts interventions that recognize and address the needs, deficits, and supports of each Enrollee based on the unique set of strengths, resources, and motivations that he or she brings;
2.5.2.1.8. Meaningfully involves the Enrollee and/or his or her designee in all phases of the Care Management process including in the assessment of needs, development of a care plan, identification of ICT members (if applicable), delivery of care and support services, and evaluation of the effectiveness and impact of care including the need for continued care or supports;
2.5.2.1.9. Provides the Enrollee with the primary decision-making role in identifying his or her needs, preferences and strengths, and a shared decision making role in determining the services and supports that are most effective and helpful;
2.5.2.1.10. Leverages existing community resources and engages the Enrollee’s informal support system to address Enrollee needs;
2.5.2.1.11. Provides direct high-touch, often face-to-face contact throughout the Care Management process between Care Managers/providers and the Enrollee;
2.5.2.1.12. Facilitates a partnership among the Enrollee, their Family, Health Care Professionals, and treatment team coordinators;
2.5.2.1.13. Provides the Enrollee the right ...
Care Delivery Model.
A. Primary Care The PCP must:
1. Provide primary medical services, including acute and preventive care;
2. Refer the Enrollee, in coordination with the ICT and in accordance with the Contractor’s policies, to Covered Service providers, as medically appropriate; and
3. Lead the ICT, together with the Care Coordinator, and if indicated, with the behavioral health clinician.
B. Interdisciplinary Care Team (ICT)
1. The Contractor must arrange for each Enrollee, in a manner that respects the needs and preferences of the Enrollee, the formation and operation of an ICT. The Contractor will ensure that each Enrollee’s care is integrated and coordinated within the framework of an ICT and that each ICT member has a defined role appropriate to his or her licensure and relationship with the Enrollee. The Enrollee will be encouraged to identify individuals he or she would like to participate on the ICT.
2. The ICT will consist of at least the following staff: a. PCP;
Care Delivery Model. A. The Health Plan shall:
1. Ensure Enrollees receive all Covered Services in the amount, duration, scope, and manner as identified through the person-centered assessment and service planning process.
2. Ensure all Covered Services are provided through a fully integrated delivery system.
3. Ensure all Covered Services are provided to Enrollees in a manner that is sensitive to the Enrollee’s functional and cognitive needs, language, and culture; allows for involvement of the Enrollee and caregivers; and is in an appropriate setting.
4. Ensure that care is person-centered and can accommodate and support self- direction.
5. Implement an evidence-based model of care (MOC) consistent with the Special Needs Plan (SNP) Model of Care, approved by the NCQA, according to the standards set forth in 42 CFR § 422.4(a)(iv), § 422.101(f), and § 422.152(g); and including the IDHW requirements identified below:
a) Description of the Plan-specific Target Population;
b) Measurable Goals;
c) Staff Structure and Care Management Goals;
d) ICT;
e) Provider Network having Specialized Expertise and Use of Clinical Practice Guidelines and Protocols;
f) MOC Training for Personnel and Provider Network;
g) Comprehensive Health Risk Assessment;
h) Individualized Care Plan;
i) Integrated Communication Network;
j) Care Management for the Most Vulnerable Subpopulations; and
k) Performance and Health Outcomes Measurement.
6. Develop practice standards in consultation with in-network health care professionals, consistent with practice standards set forth by leading academic and national clinical organizations, considering the needs of the Enrollees. Practice standards shall be reviewed and updated as appropriate.
7. Disseminate the practice standards to all affected Providers, and upon request, to Enrollees and Potential Enrollees.
8. Include the practice standards in Network Provider Subcontracts.
9. Review Provider practices to ensure compliance with the practice standards.
10. Ensure decisions for utilization management, Enrollee education, coverage of services, and other areas to which the practice standards apply are consistent with the practice standards.
11. Coordinate with Providers and other payers, as appropriate, to coordinate Enrollee care and benefits. Support a Medical Home for each Enrollee, which will be led by a PCP and Care Coordinator. The Medical Home shall form the foundation of the ICT which will ensure the integration of the Enrollee’s medical, behavioral health, subs...
Care Delivery Model. The Health Plan shall:
Care Delivery Model
