Care Management Services Clause Samples
The Care Management Services clause defines the scope and responsibilities related to the coordination and oversight of healthcare services provided to individuals. Typically, this clause outlines the specific services included, such as patient assessments, care planning, and ongoing monitoring, and may specify the roles of care managers or providers involved. Its core practical function is to ensure that patients receive comprehensive, coordinated care, thereby improving health outcomes and streamlining service delivery.
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 Contractor and accessible twenty-four
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. 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. When Your Claim is Paid................................................
Care Management Services. 1. The PHP shall provide care management, according to the Care Plan developed, to each high-need Member or through a contracted AMH, consistent with local care management requirements.
2. The PHP shall ensure that care management includes:
i. Coordination of physical, behavioral health and social services;
ii. Medication management, including regular medication reconciliation and support of medication adherence;
iii. Progress tracking through routine care team reviews;
iv. Referral follow up;
v. Peer support;
vi. Training on self-management, as relevant;
vii. Transitional care management (as described below), as needed; and
viii. For InCK-enrolled Members, additional coordination with school-based supports and services, child welfare, juvenile justice and/or early childhood services, as relevant.
3. The PHP shall ensure that the care management approach includes help for Members in addressing unmet resource needs. The PHP shall, at a minimum:
i. Use the “NC Resource Platform” to identify community-based resources and connect Members to such resources, to the extent the “NC Resource Platform” is available to support such a connection. The Department anticipates this functionality will be ready for PHP use by Contract Year 1.
a) The PHP shall use the NC Resource Platform for its community-based organization and social service agency database/directory to identify local community-based resources.
b) The PHP shall use the NC Resource Platform for referring Members to the community-based organizations and social service agencies available on the NC Resource Platform and for tracking closed loop referrals once such functionality is ready for PHP use. The PHP may use existing platforms for this capability until the NC Resource Platform is certified as fully functional and ready for statewide PHP adoption.
ii. Provide in-person assistance securing health-related services that can improve health and family well-being, including assistance filling out and submitting applications, at a minimum to:
a) Food and Nutrition Services;
b) Temporary Assistance for Needy Families;
c) Child Care Subsidy;
d) Low Income Energy Assistance Program.;
e) Women, Infants and Children (WIC);
f) Free and Reduced Lunch (FRL); and
g) School-based services for children with exceptional needs.
iii. Have a housing specialist on staff or on contract who can assist individuals who are homeless in securing housing; and
iv. Provide access to medical-legal partnerships for legal issues adversely...
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 social service staff will be required when the Enrollee is in need of the following services: 1) pre-petition screening, preadmission screening or Home and Community-Based services; 2) Child protection; 3) court ordered treatment; 4) developmental disabilities; 5) assessment of medical barriers to employment; or 6) a STATE medical review team or social security disability determination. It may also involve working with Local Agency social service staff or county attorney staff for Enrollees who are the victims or perpetrators in criminal cases. If the MCO determines that an assessment is required in order for the Enrollee to receive Covered Services related to these conditions, the MCO is responsible for payment of the assessments, unless the requested assessment has been paid for by a MCO within the previous one hundred and eighty (180) days.
(D) Procedures and criteria for making referrals to specialists and sub-specialists.
(E) Capacity to implement, when indicated, Care Management functions such as:
1) individual needs assessment, including screening for special needs (e.g. menta...