Care Management Services. CalOptima shall offer its assistance for Care Management Services for Members through its Care Management Department.
Care Management Services for All Enrollees 133
Care Management Services. The MCO shall be responsible for the Care Management of all Enrollees. The MCO’s Care Management system must be designed to coordinate the provision of primary care and all other Covered Services to its Enrollees and must promote and assure service accessibility, attention to individual needs, continuity of care, comprehensive and coordinated service delivery, the provision of culturally appropriate care, and fiscal and professional accountability. At a minimum, the MCO’s Care Management system must incorporate the following elements:
Care Management Services. Member information shall be maintained by the Contractor and accessible twenty- four (24) hours per day seven (7) days per week by members of the Care Management Team. The Contractor must develop and adopt policies and procedures to ensure all Members have access to required services. At a minimum, Members shall have available the following services:
a. Assignment to a Care Management team: The Contractor must assign a point of contact for each Member. The Contractor shall assign Members in the high risk and medium risk categories to a specific Care Management team member;
b. Access to a Member services call center;
c. Assistance with care coordination and access to primary care, behavioral health, preventive and specialty care, as needed;
d. Coordination of discharge planning;
e. Coordination with other health and social programs such as MSDH’s PHRM/ISS Program, Individuals with Disabilities Education Act (IDEA),the Special Supplemental Food Program for Women, Infants, and Children (WIC); Head Start; school health services, and other programs for children with special health care needs, such as the Title V Maternal and Child Health Program, and the Department of Human Services;
Care Management Services. The MCO shall be responsible for the Care Management of all Enrollees. The MCO’s Care Management system must be designed to coordinate the provision of primary care and all other Covered Services to its Enrollees and must promote and assure service accessibility, attention to individual needs, continuity of care, comprehensive and coordinated service delivery, the provision of culturally appropriate care, and fiscal and professional accountability. At a minimum, the MCO’s Care Management system must incorporate the following elements:
(A) Procedures for the provision of an individual needs assessment, diagnostic assessment, the development of an individual treatment plan as necessary based on the needs assessment, the establishment of treatment objectives, the monitoring of outcomes, and a process to ensure that treatment plans are revised as necessary. These procedures must be designed to accommodate the specific cultural and linguistic needs of the MCO’s Enrollees.
Care Management Services. Member information shall be maintained by Contractor and accessible twenty-four
Care Management Services. Network will make available, as necessary, the services of licensed professional(s) and support staff to perform chronic care management services on behalf of Group with respect to Group patient/members who are identified by Group as eligible for CCM Services. The elements of CCM Services to be provided by Network or Group are identified on Schedule 1 attached hereto and incorporated herein by this reference. Network's licensed professionals shall be known as “Care Managers,” and together with support staff, shall be known as the “Care Management Team.” Decisions regarding the qualifications, numbers and types of individuals comprising the Care Management Team needed to fulfill Network's responsibilities hereunder will be made within the reasonable discretion of Network. The Care Management Team will report to and conduct care management services under the supervision of a Group physician and also under the direction of the Network's Director of Care Management. The Group's Medical Director will act as a clinical resource to and provide medical direction for the Care Management Team working with Group patients. Network shall cooperate with Group personnel and consult with the Group physicians and other professionals, when appropriate, to ensure high quality patient care.
Care Management Services. Caring Friends will provide or make arrangements with Intervention Associates or another agency to provide the care management services described on Exhibit A. Caring Friends will charge you for care management services on a discounted fee-for-service basis.
Care Management Services. ECI shall provide or arrange for the provision of Care Management Services, as set forth below, to Enrollees who become Program Participants, and in coordination with the respective primary care and/or treating physicians of the Program Participants. The Care Management Service provided by ECI is a nurse-based program that supports the services provided by health care providers with individual Care Management for chronically ill patients. The objective of the program is to reduce the incidence of hospitalization among patients with some combination of congestive heart failure, diabetes, respiratory disease, or other illnesses, through individual monitoring, behavioral modification and preventive health measures. ECI nursing personnel receive special training in accordance with the confidential and proprietary training materials contained in the ECI Professional Training Manual. ECI will staff the Care Management Program with one full-time equivalent for each one hundred (100) Program Participants, plus a number of support staff both within the community and at the ECI central office. The Care Management Nurse will meet with each Program Participant on an intermittent basis ranging from daily to bimonthly, and will record pertinent information utilizing a confidential and proprietary Patient Information System operating upon a hand-held computer. The Care Management Services also include weekly physical therapy/recreational group sessions with each Program Participant during which the Care Management Nurse will be assisted by physical therapists, nursing assistants and/or other staff. Program Participants will be selected for participation in the Care Management Program based upon criteria assessed using the confidential and proprietary Selection Criteria developed by ECI and approved by ALERE. Where services are delivered in the home and community centers, ECI provides the following:
1. Care coordination to improve adherence to the plan of care.
2. Availability of on call nurse 24/7 for Program Participants.
3. Connecting care: ECI personnel visit the doctor with the patient.
Care Management Services. The MCO shall be responsible for the Care Management of all Enrollees. The MCO’s Care Management system must be designed to coordinate the provision of primary care and all other Covered Services to its Enrollees and must promote and assure service accessibility, attention to individual needs, continuity of care, comprehensive and coordinated service delivery, the provision of culturally appropriate care, and fiscal and professional accountability. At a minimum, the MCO’s Care Management system must incorporate the following elements:
(A) Procedures for the provision of an individual needs assessment, diagnostic assessment, the development of an individual treatment plan as necessary based on the needs assessment, the establishment of treatment objectives, the monitoring of outcomes, and a process to ensure that treatment plans are revised as necessary. These procedures must be designed to accommodate the specific cultural and linguistic needs of the MCO’s Enrollees.
(B) A strategy to ensure that all Enrollees and/or authorized family members or guardians are involved in treatment planning and consent to the medical treatment.
(C) A method for coordinating the medical needs of an Enrollee with his or her social service needs. This may involve working with Local Agency social service staff or with the various community resources in the county. Coordination with the Local Agency
