Common use of Care Management Clause in Contracts

Care Management. The Contractor shall provide Care Management activities to appropriate Enrollees as described in this Section and further specified by EOHHS. 1. The Contractor shall proactively identify Enrollees who may benefit from Care Management activities based on the results of a systematic evaluation as described in this Section. Such evaluation shall:‌ a. Explicitly incorporate, at a minimum: 1) Enrollees with Special Health Care Needs; 2) Enrollees with LTSS needs as indicated by the results of the Care Needs Screening described in Section 2.3.B.2.g; 3) Enrollees who are identified by EOHHS as potentially in need of Care Management; 4) Enrollees who are identified by PCPs as potentially in need of Care Management; and 5) Enrollees who self-identify to the Contractor as potentially in need of Care Management; b. Incorporate information contained, if applicable and as available, in each Enrollee’s: 1) Care Needs Screening; 2) Claims or encounter data; 3) Medical records; 4) Laboratory results; 5) Pharmacy data; 6) Discharge data; and 7) Other relevant sources of information identified by the Contractor or EOHHS; and c. Incorporate predictive modeling of an Enrollee’s risk for high cost, high utilization, admission, re-admission, or other adverse health outcomes. 2. The Contractor shall provide each identified Enrollee with Care Management as follows: a. Care Management shall include, but not be limited to, activities such as: 1) Providing a Comprehensive Assessment as described in Section 2.3.D.1 2) Otherwise comprehensively assessing Enrollee’s with Special Health Care needs as described in Section 2.3.D; 3) Creating a documented Care Plan as described in Section 2.3.

Care Management. The Contractor shall provide Care Management activities to appropriate Enrollees as described in this Section and further specified by EOHHS. 1. The Contractor shall proactively identify Enrollees who may benefit from Care Management activities based on the results of a systematic evaluation as described in this Section. Such evaluation shall:‌shall: a. Explicitly incorporate, at a minimum: 1) Enrollees with Special Health Care Needs; 2) Enrollees with LTSS needs as indicated by the results of the Care Needs Screening described in Section 2.3.B.2.g; 3) Enrollees who are identified by EOHHS as potentially in need of Care Management; 4) Enrollees who are identified by PCPs PCCs as potentially in need of Care Management; and 5) Enrollees who self-identify to the Contractor as potentially in need of Care Management; b. Incorporate information contained, if applicable and as available, in each Enrollee’s: 1) Care Needs Screening; 2) Claims or encounter data; 3) Medical records; 4) Laboratory results; 5) Pharmacy data; 6) Discharge data; and 7) Other relevant sources of information identified by the Contractor or EOHHS; and c. Incorporate predictive modeling of an Enrollee’s risk for high cost, high utilization, admission, re-admission, or other adverse health outcomes. 2. The Contractor shall provide each identified Enrollee with Care Management as follows: a. Care Management shall include, but not be limited to, activities such as: 1) Providing a Comprehensive Assessment as described in Section 2.3.D.12.3.D.1 for Enrollees assigned to a BH or LTSS CP; 2) Otherwise comprehensively assessing Enrollee’s with Special Health Care needs as described in Section 2.3.D; 3) Creating a documented Care Plan as described in Section 2.3.

Care Management. The Contractor shall provide Care Management activities to appropriate Enrollees as described in this Section and further specified by EOHHS. 1. The Contractor shall proactively identify Enrollees who may benefit from Care Management activities based on the results of a systematic evaluation as described in this Section. Such evaluation shall:‌shall: a. Explicitly incorporate, at a minimum: 1) Enrollees with Special Health Care Needs; 2) Enrollees with LTSS needs as indicated by the results of the Care Needs Screening described in Section 2.3.B.2.g; 3) Enrollees who are identified by EOHHS as potentially in need of Care Management; 4) Enrollees who are identified by PCPs as potentially in need of Care Management; and 5) Enrollees who self-identify to the Contractor as potentially in need of Care Management; b. Incorporate information contained, if applicable and as available, in each Enrollee’s: 1) Care Needs Screening; 2) Claims or encounter data; 3) Medical records; 4) Laboratory results; 5) Pharmacy data; 6) Discharge data; and 7) Other relevant sources of information identified by the Contractor or EOHHS; and c. Incorporate predictive modeling of an Enrollee’s risk for high cost, high utilization, admission, re-admission, or other adverse health outcomes. 2. The Contractor shall provide each identified Enrollee with Care Management as follows: a. Care Management shall include, but not be limited to, activities such as: 1) Providing a Comprehensive Assessment as described in Section 2.3.D.1 2) Otherwise comprehensively assessing Enrollee’s with Special Health Care needs as described in Section 2.3.D; 3) Creating a documented Care Plan as described in Section 2.3.

Care Management. The Each of the Contractor’s Approved ACO Agreements with a Contracting MCO shall delineate responsibilities and define areas of collaboration between the Contractor shall and the Contracting MCO, including obligating the Contractor as appropriate, to provide Care Management activities to appropriate Enrollees Attributed Members as described in this Section and further specified by EOHHS. 1. The Approved ACO Agreement shall delineate responsibilities and define areas of collaboration between the Contractor and the Contracting MCO to, and shall obligate the Contractor to assist the Contracting MCO to, proactively identify Enrollees certain Attributed Members who may benefit from Care Management activities based on the results of a systematic evaluation as described in this Section. Such evaluation shall:‌shall: a. Explicitly incorporate, at a minimum: 1) Enrollees Attributed Members with Special Health Care Needs; 2) Enrollees Attributed Members with LTSS needs needs, as indicated by the results of the Care Needs Screening described in Section 2.3.B.2.g2.5.B.1.e; 3) Enrollees Attributed Members who are identified by EOHHS as potentially in need of Care Management; 4) Enrollees Attributed Members who are identified by PCPs as potentially in need of Care Management; and 5) Enrollees Attributed Members who self-identify to the Contractor as potentially in need of Care Management; b. Incorporate information contained, if applicable and as available, in each EnrolleeAttributed Member’s: 1) Care Needs Screening; 2) Claims or encounter data; 3) Medical records; 4) Laboratory results; 5) Pharmacy data; 6) Discharge data; and 7) Other relevant sources of information identified by the Contractor or EOHHS; and c. Incorporate predictive modeling of an EnrolleeAttributed Member’s risk for high cost, high utilization, admission, re-admission, or other adverse health outcomes. 2. The Approved ACO Agreement shall obligate the Contractor shall to provide each identified Enrollee Attributed Member with Care Management as follows: a. Care Management shall include, but not be limited to, activities such as: 1) Providing a Comprehensive Assessment as described in Section 2.3.D.12.5.D.1 for Attributed Members assigned to a BH or LTSS CP; 2) Otherwise comprehensively assessing Enrollee’s Attributed Members with Special Health Care needs Needs as described in Section 2.3.D2.5.D; 3) Creating a documented Care Plan as described in Section 2.32.5.D.2 and updating such Care Plan at least annually; 4) Providing a Care Coordinator or Clinical Care Manager who is assigned to the Attributed Member’s care; 5) Designating a care team of providers and other individuals involved in the Attributed Member's care. The care team shall include, at a minimum: a) The Attributed Member’s Care Coordinator or Clinical Care Manager; b) The Attributed Member’s PCP; c) The Attributed Member’s Behavioral Health provider (if applicable) or Contractor’s BH CP, as appropriate; d) The Attributed Member’s LTSS provider (if applicable) or Contractor’s LTSS CP, as appropriate; and e) Any additional individual requested by the Attributed Member; 6) Providing team-based Care Management, including meetings of the care team at least annually and after any major events in the Attributed Member’s care or changes in health status, or more frequently if indicated. b. The Contractor shall develop, implement, and maintain criteria and protocols for determining which Care Management activities may benefit an Attributed Member; c. The Contractor shall, at a minimum: 1) Provide a Care Coordinator who is assigned to the Attributed Member’s care for any Attributed Member with Special Health Care Needs, who is a BH CP-Assigned Attributed Members, or who is an LTSS CP Assigned Attributed Member; 2) Provide a Clinical Care Manager who is assigned to the Attributed Member’s care and a documented Care Plan based on a Comprehensive Assessment, or other assessment as described in Section 2.5.D, for any Attributed Member receiving Care Management and identified by the Contractor or EOHHS as at risk for adverse care events; and 3) Coordinate with Contractor’s BH CPs to perform outreach and engagement to any BH CP-Assigned Attributed Member, and to provide Care Management to any BH CP-Engaged Attributed Member, as described in Section 2.8.A. d. The Contractor shall develop, implement, and maintain procedures for providing, and shall provide, Care Management as follows: 1) The Contractor’s Care Management procedures shall: a) Be approved by EOHHS; b) Include procedures for acquiring and documenting Attributed Members’ consent to receive Care Management and for the Contractor to share information about an Attributed Member’s care with Attributed Members’ providers to promote coordination and integration. Contractor shall make best efforts to obtain such consent; c) Include criteria and protocols for ensuring appropriate staffing ratios and caseloads for Care Coordinators, Clinical Care Managers, and other staff involved in Care Management activities in line with industry practices; d) Include processes for the Contractor to measure the effectiveness and quality of the Contractor’s Care Management procedures. Such processes shall include: (i) Identification of relevant measurement process or outcomes; and (ii) Use of valid quantitative methods to measure outcomes against performance goals; e) Include protocols for providing Care Management activities in each of the following settings. The Contractor shall exercise best efforts to provide Care Management in such settings: (i) At adult and family shelters, for Attributed Members who are homeless; (ii) The Attributed Member’s home; (iii) The Attributed Member’s place of employment or school; (iv) At xxxxxx home, group homes and other residential placements especially for children in the care or custody of DCF and youth affiliated with DYS;); (v) At day health sites, such as for Adult Day Health; (vi) 24-hour level of care facilities for Behavioral Health or substance use disorder treatment; or (vii) Another setting of the Attributed Member’s choosing; f) Include criteria and protocols for discharging Attributed Members from Care Management; g) Ensure that the Care Management activities each Attributed Member is receiving are appropriately documented as further specified by EOHHS; and h) Ensure regular contacts between Care Management staff, the Attributed Member’s PCP, and the Attributed Member. e. For Attributed Members assigned to a BH or LTSS CP, Contractor shall coordinate with Contractor’s CPs for the provision of any Care Management activities to Attributed Members, as described in Sections 2.8.A and 2.8.B, and Contractor shall ensure that Contractor’s CPs are providing expertise and informing the development of Contractor’s Care Management policies, procedures, and programs.