Care Management Elements Sample Clauses
The Care Management Elements clause defines the specific components and responsibilities involved in managing a patient's care within a healthcare agreement. It typically outlines the roles of care coordinators, the processes for developing and updating care plans, and the communication protocols among providers. By clearly delineating these elements, the clause ensures coordinated, efficient, and accountable care delivery, reducing confusion and improving patient outcomes.
Care Management Elements. As part of the Care Management Model, the following must be provided for each member:
a. Health Needs Assessment Screening (BadgerCare Plus Childless Adults only)
1) HMOs shall conduct an initial Health Needs Assessment (HNA) Screening for Childless Adults (CLA) members within 60 days of enrollment in the HMO.
2) The HMO must perform an initial Screening for newly enrolled CLA members, and CLA members that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment.
3) The initial HNA Screening shall be conducted by appropriately qualified staff via methods that may include telephonic contact, mailings, interactive web tools, or encounters in person with screeners or health care providers.
4) Initial HNA Screening Elements – At a minimum, the HNA screening must address the following elements:
i. Urgent medical and behavioral symptoms (i.e. dyspnea, rapid weight gain/loss, syncope, suicidal ideations, psychotic break);
ii. Members’ perception of their general well-being;
iii. Identify usual sources of care (e.g. primary care provider, clinic, specialist and dental provider);
iv. Frequency in use of emergency and inpatient services;
v. History of chronic physical and mental health illness (e.g. respiratory disease, heart disease, stroke, diabetes/pre-diabetes, back pain and musculoskeletal disorders, cancer, overweight/obesity, severe mental illness, substance abuse);
vi. Number of prescription medications used monthly;
vii. Socioeconomic barriers to care (e.g. stability of housing, reliable transportation, nutrition/food resources, availability of family/caregivers to provide support);
viii. Behavioral and medical risk factors including member’s willingness to change their behavior such as:
1. Symptoms of depression
2. Alcohol consumption and substance abuse
3. Tobacco use
ix. Weight (e.g. using BMI or waist circumference) and blood pressure indicators.
5) As part of the HNA Screening process, HMOs are encouraged to assist members in identifying a primary care provider.
6) Based on member’s responses to the HNA Screening, HMOs shall conduct additional chronic or acute illness assessments as needed and identify members that may need additional care coordination.
Care Management Elements. As part of care management, the following must be provided for each member:
a. Member Needs Screening
1) The initial screen shall be conducted by appropriately qualified staff via methods that may include telephonic contact, mailings, interactive web tools (live chat, online screen), or encounters in person with screeners or health care providers.
2) Initial Screen Elements – When screening for a member’s needs, consider the following elements to gather necessary information for care management, as appropriate for the population:
a) Urgent medical and behavioral symptoms;
b) Members’ perception of their general well-being;
c) Identify usual sources of care (e.g. primary care provider, clinic, specialist and dental provider);
d) Frequency in use of emergency and inpatient services;
e) History of chronic physical and mental health illness;
f) Number of prescription medications used monthly;
g) Socioeconomic barriers to care;
h) Behavioral and medical risk factors;
i) Weight and blood pressure indicators.