Care Management Care Plans. Care management care plans will include all elements of disease management. The care plan will identify the problems, barriers and issues related to the individual’s health care needs. It will address goals, objectives and interventions to meeting the needs of the individual. The Contractor will use a multi- disciplinary team skilled in nursing, social work and behavioral health, with knowledge of local community resources to implement protocol-driven care modules for members. This will include action steps to be followed when needs are identified. This team is responsible for the initial assessment and on-going re- assessment and evaluation of care management members. Care plans should anticipate volatile healthcare needs, including a need for immediate respite, medical advice or home health care. Care management care plans should foresee possible crisis situations where immediate additional support is needed to prevent hospitalizations, long-term care or poor outcomes. The Care Plan must describe how the Contractor will manage care for these members, including after business hours. The Contractor will engage the member’s PMP (if applicable) or other significant provider(s) in care management through ongoing, direct interaction between the provider and the multidisciplinary care management team.
Care Management Care Plans. Care management care plans will include all elements of disease management. The care plan will identify the problems, barriers and issues related to the individual’s health care needs. It will address goals, objectives and interventions to meeting the needs of the individual. The Contractor will use a multi-disciplinary team skilled in nursing, social work and behavioral health, with knowledge of local community resources to implement protocol-driven care modules for members. This will include action steps to be followed when needs are identified. This team is responsible for the initial assessment and on- going re-assessment and evaluation of care management members. Care plans should anticipate volatile healthcare needs, including a need for immediate respite, medical advice or home health care. Care management care plans should foresee possible crisis situations where immediate additional support is needed to prevent hospitalizations, long-term care or poor outcomes. Respondents must describe how they would manage care for these members, including after business hours. The Contractor will engage the member’s PMP (if applicable) or other significant provider(s) in care management through ongoing, direct interaction between the provider and the multidisciplinary care management team. This involvement will include semi- annual care conferences based on the member’s assessment and evaluation. The Contractor will offer to travel to the provider’s office to conduct the care conference, or conduct it via teleconference, at the provider’s option. A minimum of two (2) weeks prior to each care conference, the Contractor will solicit input from the member’s provider for updating the care plan and consideration for appropriate stratification. Contractors shall reimburse providers for their time at these care conferences as described further in Section 3.5.
