Common use of Care Management for At-Risk Children Clause in Contracts

Care Management for At-Risk Children. (a) LHD shall accept referrals from Health Plan for child Members identified as requiring Care Management for At-Risk Children. (b) LHD shall educate patients, Advanced Medical Homes, other practices and community organizations about the benefits of the Care Management for At-Risk Children Program and target populations for referral; disseminate the Care Management for At-Risk Children Referral Form either electronically and/or in a paper version to potential referral sources. (c) LHD shall communicate regularly with the Advanced Medical Homes and other practice serving children, to ensure that children served by that medical home are appropriately identified for Care Management for At-Risk Children services. (d) LHD shall collaborate with out-of-county Advanced Medical Homes and other practices to facilitate cross-county partnerships to optimize care for Members who receive services from outside their resident county. (e) LHD shall identify or develop if necessary, a list of community resources available to meet the specific needs of the population. (f) LHD shall utilize the NC Resource Platform, when operational, and identify additional community resources and other supportive services once the platform has been fully certified by the Department. (g) LHD shall use any claims-based reports and other information provided by Health Plan, as well as Care Management for At-Risk Children Referral Forms received to identify priority populations. (h) LHD shall establish and maintain contact with referral sources to assist in methods of identification and referral for the target population. (i) LHD shall communicate with the medical home and other primary care clinician about the Care Management for At-Risk Children target group and how to refer to the Care Management for At-Risk Children program. (j) LHD shall involve families (or legal guardian when appropriate) in the decision- making process through a Member-centered, collaborative partnership approach to assist with improved self-care. (k) LHD shall xxxxxx self-management skill building when working with families of child Members. (l) LHD shall prioritize face-to-face family interactions (home visit, PCP office visit, hospital visit, community visit, etc.) over telephone interactions for child Members in active case status, when possible. (m) LHD shall use the information gathered during the assessment process to determine whether the child Member meets the Care Management for At-Risk Children target population description. (n) LHD shall review and monitor Health Plan reports created for Care Management for At-Risk Children, along with the information obtained from the family, to assure the child Member is appropriately linked to preventive and primary care services and to identify Members at risk. (o) LHD shall use the information gained from the assessment to determine the need for and the level of service to be provided. (p) LHD shall provide information and/or education to meet families’ needs and encourage self-management using materials that meet literacy standards. (q) LHD shall ensure children/families are well-linked to the Member’s Advanced Medical Home or other practice; provide education about the importance of the medical home. (r) LHD shall provide care management services in accordance with program guidelines, including condition-specific pathways, utilizing those interventions that are most effective in engaging Members, meeting their needs and achieving care plan goals. (s) LHD shall identify and coordinate care with community agencies/resources to meet the specific needs of the Member; use any locally-developed resource list (including NC Resource Platform) to ensure families are well linked to resources to meet the identified need. (t) LHD shall provide care management services based upon the Member’s level of need as determined through ongoing assessment. (u) LHD shall collaborate with Advanced Medical Home/PCP/care team to facilitate implementation of Member-centered plans and goals targeted to meet individual Member’s needs. (v) LHD shall ensure that changes in the care management level of care, need for Member support and follow up and other relevant updates (especially during periods of transition) are communicated to the Advanced Medical Home PCP and/or care team. (w) Where care management is being provided by Health Plan and/or Advanced Medical Home practice in addition to the Care Management for At-Risk program, the Health Plan/AMH practice must explicitly agree on the delineation of responsibility and document that agreement in the Member’s Plan of Care to avoid duplication of services (x) LHD shall ensure that changes in the care management level of care, need for Member support and follow up and other relevant updates (especially during periods of transition) are communicated to the Advanced Medical home PCP and/or care team and to Health Plan. (y) LHD shall ensure awareness of Health Plan Member's “in network” status with providers when organizing referrals. (z) LHD shall ensure understanding of Health Plan’s prior authorization processes relevant to referrals. (aa) LHD shall document all care management activities in the care management documentation system in a timely manner. (bb) LHD shall ensure that the services provided by Care Management for At-Risk Children meet a specific need of the family and work collaboratively with the family and other service providers to ensure the services are provided as a coordinated effort that does not duplicate services. (cc) LHD shall participate in Department/Health Plan sponsored webinars, trainings and continuing education opportunities as provided. (dd) LHD shall pursue ongoing continuing education opportunities to stay current in evidence-based care management of high-risk children. (ee) LHD shall hire care managers meeting Care Management for At-Risk Children care coordination competencies and with at least one of the following qualifications: (i) Registered nurses; (ii) Social workers with a bachelor’s degree in social work (BSW, BA in SW, or BS in SW) or master’s degree in social work (MSW, MA in SW, or MS in SW) from a Council on Social Work Education accredited social work degree program. Non-degreed social workers cannot be the lead care manager providing Care Management for At-Risk Children even if they qualify as a Social Worker under the Office of State Personnel guidelines. (ff) LHD shall engage care managers who operate with a high level of professionalism and possess an appropriate mix of skills needed to work effectively with high-risk children. This skill mix must reflect the capacity to address the needs of Members with both medically and socially complex conditions. (gg) LHD shall ensure that Care Management for At-Risk Children Care Managers must demonstrate: (i) Proficiency with the technologies required to perform care management functions – particularly as pertains to claims data review and care management documentation system; (ii) ability to effectively communicate with families and providers; (iii) Critical thinking skills, clinical judgment and problem- solving abilities; and (iv) motivational interviewing skills, Trauma Informed Care, and knowledge of adult teaching and learning principles. (hh) LHD shall ensure that the team of Care Management for At-Risk Children care managers shall include both registered nurses and social workers to best meet the needs of the target population with medical and psychosocial risk factors. (ii) If the LHD has only has a single Care Management for At-Risk Children care manager, the LHD shall ensure access to individual(s) to provide needed resources, consultation and guidance from the non-represented professional discipline. (jj) LHD shall maintain services during the event of an extended vacancy. (kk) In the event of an extended vacancy, LHD shall complete and submit the vacancy contingency plan that describes how an extended staffing vacancy will be covered and the plan for hiring if applicable. (ll) LHD shall establish staffing arrangements to ensure continuous service delivery through appropriate management of staff vacancies and extended absences, including following Department guidance regarding vacancies or extended staff absences and adhering to DHHS guidance about contingency planning to prevent interruptions in service delivery. Vacancies lasting longer than 60 days will be subject to additional oversight. (mm) LHD shall ensure that Community Health Workers and other unlicensed staff work under the supervision and direction of a trained Care Management for At-Risk Children Care Manager. (nn) LHD shall provide qualified supervision and support for Care Management for At-Risk Children care managers to ensure that all activities are designed to meet performance measures, with supervision to include: (i) provision of program updates to care managers; (ii) daily availability for case consultation and caseload oversight;

Care Management for At-Risk Children. If the PO is a Local Health Department (aLHD) LHD shall accept referrals from Health Plan for child Members identified as requiring Care Management carrying out care management for At-Risk Children.: (b) LHD A. For Contract Year 1, PO/LHDs shall educate patients, Advanced Medical Homes, other practices and community organizations about have the benefits right of the first refusal to conduct Care Management for At-Risk Children Program and target populations for referral; disseminate the BH I/DD Tailored Plan-eligible children ages zero (0) to five (5) who are already enrolled in Care Management for At-Risk Children Referral Form either electronically and/or at the time of BH I/DD Tailored Plan launch. Children enrolled in a paper version to potential referral sources. (c) LHD shall communicate regularly with Care Management for At-Risk Children will not be eligible for Tailored Care Management while enrolled in Care Management for At-Risk Children because the Advanced Medical Homes and other practice serving childrentwo programs provide duplicative services. After the launch of BH I/DD Tailored Plans, to ensure that children served covered by that medical home are appropriately identified BH I/DD Tailored Plans who would otherwise h ave become eligible for Care Management for At-Risk Children serviceswill be enrolled into Tailored Care Management and not into Care Management for At-Risk Children. After Contract Year 1, Care Management for At-Risk Children shall be fully subsumed into the Tailored Care Management model. (d) B. PO/LHD shall collaborate with out-of-county Advanced Medical Homes organizations providing Tailored Care Management—AMH+ practices, CMAs, and other practices BH I/DD Tailored Plans—to facilitate cross-county partnerships to optimize care for Members patients who receive services from outside their resident county. (e) C. PO/LHD shall identify or develop develop, if necessary, a list of community resources available to meet the specific needs of the population. (f) D. PO/LHD shall utilize the NC Resource Platform, when operational, NCCARE360 to identify and identify connect members with additional community resources and other supportive services once the platform has been fully certified by the Departmentresources. (g) LHD shall use any claims-based reports and other information provided by Health Plan, as well as Care Management for At-Risk Children Referral Forms received to identify priority populations. (h) LHD shall establish and maintain contact with referral sources to assist in methods of identification and referral for the target population. (i) LHD shall communicate with the medical home and other primary care clinician about the Care Management for At-Risk Children target group and how to refer to the Care Management for At-Risk Children program. (j) E. PO/LHD shall involve families (or a legal guardian guardian, when appropriate) in the decision- decision-making process through a Memberpatient-centered, collaborative partnership approach to assist with improved self-care. (k) F. PO/LHD shall xxxxxx self-management skill building when working with families of child Memberschildren. (l) G. PO/LHD shall prioritize face-to-face family interactions (home visit, PCP office visit, hospital visit, community visit, etc.) over telephone interactions for child Members children in active case status, when possible. (m) LHD shall use the information gathered during the assessment process to determine whether the child Member meets the Care Management for At-Risk Children target population description. (n) H. PO/LHD shall review and monitor Health BH I/DD Tailored Plan reports created for Care Management for At-At- I. Risk Children, along with the information obtained from the family, to assure ensure the child Member is appropriately linked to preventive and primary care services and to identify Members individuals at risk. (o) J. PO/LHD shall use the information gained from the assessment to determine the need for services and the level of service to be provided. (p) K. PO/LHD shall provide information and/or education to meet families’ needs and encourage self-management using materials that meet literacy standards. (q) L. PO/LHD shall ensure children/families are well-well linked to the Memberchild’s Advanced Medical Home or other practice; provide education about the importance of the medical homePCP. (r) M. PO/LHD shall provide care management services in accordance with program guidelines, including condition-specific pathways, utilizing those interventions that are most effective in engaging Memberspatients, meeting their needs and achieving care plan Care Plan goals. (s) N. PO/LHD shall identify and coordinate care with community agencies/resources to meet the specific needs of the Member; child and use any locally-locally developed resource list (including NC Resource PlatformNCCARE360) to ensure families are well linked to resources to meet the identified need. (t) O. PO/LHD shall provide care management services based upon the Memberpatient’s level of need as determined through ongoing assessment. (u) P. PO/LHD shall collaborate with Advanced Medical Home/PCP/care team the member’s PCP to facilitate implementation of Memberpatient-centered plans and goals targeted to meet individual Memberchildren’s needs. (v) Q. PO/LHD shall ensure that changes in the care management level of care, care or in the need for Member patient support and follow follow-up and other relevant updates (especially during periods of transition) are communicated to the Advanced Medical Home PCP and/or care team. (w) Where care management is being provided by Health Plan and/or Advanced Medical Home practice in addition and to the Care Management for At-Risk program, the Health PlanBH I/AMH practice must explicitly agree on the delineation of responsibility and document that agreement in the Member’s Plan of Care to avoid duplication of services (x) LHD shall ensure that changes in the care management level of care, need for Member support and follow up and other relevant updates (especially during periods of transition) are communicated to the Advanced Medical home PCP and/or care team and to Health DD Tailored Plan. (y) R. PO/LHD shall ensure awareness of Health BH I/DD Tailored Plan Member's members’ “in network” status with providers when organizing referrals. (z) S. PO/LHD shall ensure understanding of Health Plan’s BH I/DD Tailored Plans’ prior authorization processes relevant to referrals. (aa) T. PO/LHD shall document all care management activities in the care management documentation system in a timely manner. (bb) U. PO/LHD shall ensure that the services provided by Care Management for At-Risk Children meet a specific need of the family and shall work collaboratively with the family and other service providers to ensure the services are provided as a coordinated effort that does not duplicate services. (cc) V. PO/LHD shall participate in DepartmentDepartment or BH I/Health Plan DD Tailored Plan-sponsored webinars, trainings and continuing education opportunities as provided. (dd) W. PO/LHD shall pursue ongoing continuing education opportunities to stay current in evidence-based care management of high-risk children. (ee) X. PO/LHD shall hire care managers meeting who meet Care Management for At-Risk Children care coordination competencies and with have at least one of the following qualifications: (i) : 1. Registered nurses; (ii) 2. Social workers with a bachelorBachelor’s degree in social work (BSW, BA in SW, or BS in SW) or masterMaster’s degree in social work (MSW, MA in SW, or MS in SW) from a Council on Social Work Education Education-accredited social work degree program. . (a) Non-degreed social workers cannot be the lead care manager providing Care Management for At-Risk Children even if they qualify as a Social Worker social workers under the Office of State Personnel guidelines. (ff) Y. PO/LHD shall engage care managers who operate with a high level of professionalism and possess an appropriate mix of skills needed to work effectively with high-risk children. This skill mix must reflect the capacity to address the needs of Members patients with both medically and socially complex conditions. (gg) Z. PO/LHD shall ensure that Care Management for At-Risk Children Care Managers must care managers demonstrate: (i) : 1. Proficiency with the technologies required to perform care management functions – functions—particularly as pertains to claims data review and the care management documentation system; (ii) ability 2. Ability to effectively communicate with families and providers; (iii) 3. Critical thinking skills, clinical judgment judgment, and problem- problem-solving abilities; and (iv) motivational 4. Motivational interviewing skills, Trauma Informed Careknowledge of trauma-informed care, and knowledge of adult teaching and learning principles. (hh) principles AA. PO/LHD shall ensure that the team of Care Management for At-Risk Children care managers shall include both registered nurses and social workers to best meet the needs of the target population with medical and psychosocial risk factors. (ii) If the LHD has only has a single Care Management for At-Risk Children care manager, the LHD shall ensure access to individual(s) to provide needed resources, consultation and guidance from the non-represented professional discipline. (jj) LHD shall maintain services during the event of an extended vacancy. (kk) In the event of an extended vacancy, LHD shall complete and submit the vacancy contingency plan that describes how an extended staffing vacancy will be covered and the plan for hiring if applicable. (ll) LHD shall establish staffing arrangements to ensure continuous service delivery through appropriate management of staff vacancies and extended absences, including following Department guidance regarding vacancies or extended staff absences and adhering to DHHS guidance about contingency planning to prevent interruptions in service delivery. Vacancies lasting longer than 60 days will be subject to additional oversight. (mm) LHD shall ensure that Community Health Workers and other unlicensed staff work under the supervision and direction of a trained Care Management for At-Risk Children Care Manager. (nn) LHD shall provide qualified supervision and support for Care Management for At-Risk Children care managers to ensure that all activities are designed to meet performance measures, with supervision to include: (i) provision of program updates to care managers; (ii) daily availability for case consultation and caseload oversight;

Care Management for At-Risk Children. (a) LHD shall accept referrals from Health Plan for child Members identified as requiring Care Management for At-Risk Children. (b) LHD shall educate patients, Advanced Medical Homes, other practices and community organizations about the benefits of the Care Management for At-Risk Children Program and target populations for referral; disseminate the Care Management for At-At- Risk Children Referral Form either electronically and/or in a paper version to potential referral sources. (c) LHD shall communicate regularly with the Advanced Medical Homes and other practice serving children, to ensure that children served by that medical home are appropriately identified for Care Management for At-Risk Children services. (d) LHD shall collaborate with out-of-county Advanced Medical Homes and other practices to facilitate cross-county partnerships to optimize care for Members who receive services from outside their resident county. (e) LHD shall identify or develop if necessary, a list of community resources available to meet the specific needs of the population. (f) LHD shall utilize the NC Resource Platform, when operational, and identify additional community resources and other supportive services once the platform has been fully certified by the Department. (g) LHD shall use any claims-based reports and other information provided by Health Plan, as well as Care Management for At-Risk Children Referral Forms received to identify priority populations. (h) LHD shall establish and maintain contact with referral sources to assist in methods of identification and referral for the target population. (i) LHD shall communicate with the medical home and other primary care clinician about the Care Management for At-Risk Children target group and how to refer to the Care Management for At-Risk Children program. (j) LHD shall involve families (or legal guardian when appropriate) in the decision- making process through a Member-centered, collaborative partnership approach to assist with improved self-care. (k) LHD shall xxxxxx self-management skill building when working with families of child Members. (l) LHD shall prioritize face-to-face family interactions (home visit, PCP office visit, hospital visit, community visit, etc.) over telephone interactions for child Members in active case status, when possible. (m) LHD shall use the information gathered during the assessment process to determine whether the child Member meets the Care Management for At-Risk Children target population description. (n) LHD shall review and monitor Health Plan reports created for Care Management for At-Risk Children, along with the information obtained from the family, to assure the child Member is appropriately linked to preventive and primary care services and to identify Members at risk. (o) LHD shall use the information gained from the assessment to determine the need for and the level of service to be provided. (p) LHD shall provide information and/or education to meet families’ needs and encourage self-management using materials that meet literacy standards. (q) LHD shall ensure children/families are well-linked to the Member’s Advanced Medical Home or other practice; provide education about the importance of the medical home. (r) LHD shall provide care management services in accordance with program guidelines, including condition-specific pathways, utilizing those interventions that are most effective in engaging Members, meeting their needs and achieving care plan goals. (s) LHD shall identify and coordinate care with community agencies/resources to meet the specific needs of the Member; use any locally-developed resource list (including NC Resource Platform) to ensure families are well linked to resources to meet the identified need. (t) LHD shall provide care management services based upon the Member’s level of need as determined through ongoing assessment. (u) LHD shall collaborate with Advanced Medical Home/PCP/care team to facilitate implementation of Member-centered plans and goals targeted to meet individual Member’s needs. (v) LHD shall ensure that changes in the care management level of care, need for Member support and follow up and other relevant updates (especially during periods of transition) are communicated to the Advanced Medical Home PCP and/or care team. (w) Where care management is being provided by Health Plan and/or Advanced Medical Home practice in addition to the Care Management for At-Risk program, the Health Plan/AMH practice must explicitly agree on the delineation of responsibility and document that agreement in the Member’s Plan of Care to avoid duplication of services (x) LHD shall ensure that changes in the care management level of care, need for Member support and follow up and other relevant updates (especially during periods of transition) are communicated to the Advanced Medical home PCP and/or care team and to Health Plan. (y) LHD shall ensure awareness of Health Plan Member's “in network” status with providers when organizing referrals. (z) LHD shall ensure understanding of Health Plan’s prior authorization processes relevant to referrals. (aa) LHD shall document all care management activities in the care management documentation system in a timely manner. (bb) LHD shall ensure that the services provided by Care Management for At-Risk Children meet a specific need of the family and work collaboratively with the family and other service providers to ensure the services are provided as a coordinated effort that does not duplicate services. (cc) LHD shall participate in Department/Health Plan sponsored webinars, trainings and continuing education opportunities as provided. (dd) LHD shall pursue ongoing continuing education opportunities to stay current in evidence-based care management of high-risk children. (ee) LHD shall hire care managers meeting Care Management for At-Risk Children care coordination competencies and with at least one of the following qualifications: (i) Registered nurses; (ii) Social workers with a bachelor’s degree in social work (BSW, BA in SW, or BS in SW) or master’s degree in social work (MSW, MA in SW, or MS in SW) from a Council on Social Work Education accredited social work degree program. Non-degreed social workers cannot be the lead care manager providing Care Management for At-Risk Children even if they qualify as a Social Worker under the Office of State Personnel guidelines. (ff) LHD shall engage care managers who operate with a high level of professionalism and possess an appropriate mix of skills needed to work effectively with high-risk children. This skill mix must reflect the capacity to address the needs of Members with both medically and socially complex conditions. (gg) LHD shall ensure that Care Management for At-Risk Children Care Managers must demonstrate: (i) Proficiency with the technologies required to perform care management functions – particularly as pertains to claims data review and care management documentation system; (ii) ability to effectively communicate with families and providers; (iii) Critical thinking skills, clinical judgment and problem- solving abilities; and (iv) motivational interviewing skills, Trauma Informed Care, and knowledge of adult teaching and learning principles. (hh) LHD shall ensure that the team of Care Management for At-Risk Children care managers shall include both registered nurses and social workers to best meet the needs of the target population with medical and psychosocial risk factors. (ii) If the LHD has only has a single Care Management for At-Risk Children care manager, the LHD shall ensure access to individual(s) to provide needed resources, consultation and guidance from the non-represented professional discipline. (jj) LHD shall maintain services during the event of an extended vacancy. (kk) In the event of an extended vacancy, LHD shall complete and submit the vacancy contingency plan that describes how an extended staffing vacancy will be covered and the plan for hiring if applicable. (ll) LHD shall establish staffing arrangements to ensure continuous service delivery through appropriate management of staff vacancies and extended absences, including following Department guidance regarding vacancies or extended staff absences and adhering to DHHS guidance about contingency planning to prevent interruptions in service delivery. Vacancies lasting longer than 60 days will be subject to additional oversight. (mm) LHD shall ensure that Community Health Workers and other unlicensed staff work under the supervision and direction of a trained Care Management for At-Risk Children Care Manager. (nn) LHD shall provide qualified supervision and support for Care Management for At-At- Risk Children care managers to ensure that all activities are designed to meet performance measures, with supervision to include: (i) provision of program updates to care managers; (ii) daily availability for case consultation and caseload oversight;