Common use of Care Model Clause in Contracts

Care Model. The vision of the ACC Program is to transform the health care delivery system from a traditional, unmanaged FFS model to a regional, outcome-focused, client/family- centered coordinated system of care. Under the ACC, payment to providers continues to be on a FFS basis, and beneficiaries remain free to choose among all participating Medicaid (and, in this Demonstration, Medicare) providers. However, through the seven Regional Care Collaborative Organizations, the ACC creates an accountability structure missing from a typical unmanaged FFS delivery system. The ACC model drives primary care reform through Primary Care Medical Providers. PCMPs provide whole-person, coordinated, culturally-competent care for beneficiaries. Through the ACC, participating PCMPs are eligible to receive per member per month payments and required to offer increased access to beneficiaries through, for example, extended office hours or same-day appointments. RCCOs also manage virtual networks of providers to promote beneficiary access to care and support providers with clinical tools, data, and analytics. The Demonstration will modify the existing ACC Program framework to support the potentially complex needs of Medicare-Medicaid enrollees and the particular financing of their services. The State will work with RCCOs, PCMPs, and other providers and systems of care to ensure that appropriate, high-quality care coordination is available for all beneficiaries who are served under the Demonstration. The Demonstration will include the full continuum of Medicare and Medicaid services that individuals eligible for both programs are entitled to receive, including Medicare Parts A and B and Part D, and all Medicaid State Plan and appropriate waiver services. Each beneficiary in the Demonstration will be enrolled with the RCCO serving his/her area of the State. For beneficiaries attributed to a PCMP, the RCCO or its designee will perform a comprehensive in-person health screening and work with the beneficiary to complete a Plan of Care within 60 days of enrollment in the RCCO. The Plan of Care articulates the beneficiary’s short- and long-term goals and objectives, and it becomes the blueprint for meeting beneficiary goals and improving The Plan of Care will provide a single, comprehensive view of all elements needed to coordinate a Demonstration enrollee’s physical, behavioral, and social health care, services, and supports. It ensures communication and coordination with the beneficiary, across delivery systems, and among providers. To support beneficiaries in implementing their Plans of Care, RCCOs will offer care coordination, either through RCCO staff or arrangements with local providers. RCCOs and PCMPs coordinate with direct services providers to arrange for timely post-institutional or facility discharge follow-up, including medication reconciliation and substance use treatment and mental health after care. RCCOs will be responsible for ensuring Plan of Care completion and timely review and updates and for providing training and guidance as needed. Where clients may have care plans through SEPs, CCBs, BHOs, or other Medicaid providers, the Plan of Care is meant to complement the existing care plans done for clients. Many Medicare-Medicaid beneficiaries already have limited-service care management through HCBS waivers of the specialty mental health system. Under the Demonstration, the State does not intend to add another care coordinator or case manager to the existing systems of care for Medicare-Medicaid enrollees. Instead, the RCCOs will work collaboratively with current systems of care to achieve a more effective and streamlined approach to services for beneficiaries. These collaborative activities may include but are not limited to RCCOs notifying home health organizations of inpatient admission or discharge dates, RCCOs assisting clients on waiting lists for HCBS waiver services, providing access to the PCMP directory to identify a list of possible medical homes for clients, referring clients that could benefit from SEP or CCB or RCCO services, and assistance with finding clients and connecting them with medical homes. Care coordination for Medicare-Medicaid enrollees, in particular, will be flexible enough to respond when a beneficiary’s needs increase or decrease. The State has worked collaboratively to develop enhanced care coordination requirements for different groups of Medicare-Medicaid enrollees, and RCCOs are continuing to develop relationships with community providers serving persons with physical and developmental disabilities. While the Plan of Care and new care coordination opportunities drive improvement at the beneficiary level, the Demonstration will create new relationships across primary and acute care, LTSS, and behavioral health systems. In support of Medicare- Medicaid beneficiaries in the Demonstration, RCCOs have worked collaboratively with SEPs, CCBs, BHOs, hospitals, home health organizations, disability organizations, skilled nursing facilities, and hospice organizations to establish and test written protocols in their corresponding regions and communities. These protocols have been approved by the Demonstration’s Advisory Subcommittee and recommended to the Department for use during readiness for and implementation of the Demonstration. Reference to the protocols has been included in RCCO contract amendments.

Care Model. Colorado will share any proposed changes to the written protocols 30 days in advance of the effective date for CMS review and comment. The vision of the ACC Accountable Care Collaborative (ACC) Program is to transform the health care delivery system from a traditional, unmanaged FFS model to a regional, outcome-focused, client/family- family-centered coordinated system of care. Under the ACC, payment to providers continues to be on a FFS basis, and beneficiaries remain free to choose among all participating Medicaid (and, in this Demonstration, Medicare) providers. However, through the seven Regional Care Collaborative OrganizationsOrganizations (RCCOs), the ACC creates an accountability structure missing from a typical unmanaged FFS delivery system. The ACC model drives primary care reform through Primary Care Medical ProvidersProviders (PCMPs). PCMPs provide whole-person, coordinated, culturally-competent care for beneficiaries. Through the ACC, participating PCMPs are eligible to receive per member per month payments and required to offer increased access to beneficiaries through, for example, extended office hours or same-day appointments. RCCOs also manage virtual networks of providers to promote beneficiary access to care and support providers with clinical tools, data, and analytics. The Demonstration will modify the existing ACC Program framework to support the potentially complex needs of Medicare-Medicaid enrollees and the particular financing of their services. The State will work with RCCOs, PCMPs, and other providers and systems of care to ensure that appropriate, high-quality care coordination is available for all beneficiaries who are served under the Demonstration. The Demonstration will include the full continuum of Medicare and Medicaid services that individuals eligible for both programs are entitled to receive, including Medicare Parts A and B and Part D, and all Medicaid State Plan and appropriate waiver services. Each beneficiary in the Demonstration will be enrolled with the RCCO serving his/her area of the State. For beneficiaries attributed to a PCMP, the The RCCO or its designee will perform a comprehensive in-person health screening and work with the beneficiary to complete a Service Coordination Plan of Care (SCP) for each beneficiary enrolled in the Demonstration. Beneficiaries determined to be high-risk must have a SCP completed within 60 90 days of enrollment in the RCCOdemonstration. All other beneficiaries must have a SCP completed within 120 days of enrollment. The Plan of Care SCP articulates the beneficiary’s short- and long-term goals and objectives, objectives and it becomes the blueprint for meeting beneficiary goals and improving health outcomes. The Plan RCCOs and PCMPs will use a SCP that contains required, standardized elements to collaborate with the beneficiary and to facilitate coordination among the beneficiary’s other service providers. The SCP will include the beneficiary’s basic demographic information; release of Care information; cultural and linguistic considerations; prioritized domains of care; available interventions and potential methods; contacts and objective timelines; and timeframes for updates and revisions. The SCP will be developed based on protocols developed by the RCCOs. To prevent duplication, strengthen relationships, and improve coordination in serving Demonstration enrollees, RCCOs have worked collaboratively with Single Entry Points (SEPs), Community Centered Boards (CCBs), Behavioral Health Organizations (BHOs), hospitals, home health organizations, disability organizations, skilled nursing facilities, and hospice organizations to establish written protocols. The protocols describe the process for identifying and working with beneficiaries, fulfilling existing responsibilities and mutually agreed upon support functions, and establishing regular contact and communication. The SCP will be reviewed no less frequently than every six months by the RCCOs and PCMPs, the beneficiary, and the beneficiary’s other case managers and updated accordingly. The SCP will be intended to complement, rather than duplicate, other assessments or care plans currently in place (e.g., through HCBS waiver programs). The SCP will provide a single, comprehensive view of all elements needed to coordinate a Demonstration enrollee’s physical, behavioral, and social health care, services, and supports. It ensures will ensure communication and coordination with the beneficiary, across delivery systems, and among providers. To support beneficiaries in implementing their Plans of CareSCP, RCCOs will offer care coordination, either through RCCO staff or arrangements with local providers. RCCOs and PCMPs will coordinate with direct services providers to arrange for timely post-institutional or facility discharge follow-up, including medication reconciliation and substance use treatment and mental health after care. RCCOs will be responsible for ensuring Plan of Care SCP completion and timely review and updates and for providing training and guidance as needed. Where clients may have care plans through SEPs, CCBs, BHOs, or other Medicaid providers, the Plan of Care is meant to complement the existing care plans done for clients. Many MedicareMedicaid-Medicaid beneficiaries already have limited-service care management through HCBS waivers of the specialty mental health system. Under the Demonstration, the State does not intend to add another care coordinator or case manager to the existing systems of care for Medicare-Medicaid enrollees. Instead, the RCCOs will work collaboratively with current systems of care to achieve a more effective and streamlined approach to services for beneficiaries. These collaborative activities may include but are not limited to RCCOs notifying home health organizations of inpatient admission or discharge dates, RCCOs assisting clients on waiting lists for HCBS waiver services, providing access to the PCMP directory to identify a list of possible medical homes for clients, referring clients that could benefit from SEP or CCB or RCCO services, and assistance with finding clients and connecting them with medical homes. Care coordination for Medicare-Medicaid enrollees, in particular, will be flexible enough to respond when a beneficiary’s needs increase or decrease. The State has worked collaboratively to develop enhanced care coordination requirements for different groups of Medicare-Medicare- Medicaid enrollees, and RCCOs are continuing to develop relationships with community providers serving persons with physical and developmental disabilities. While the Plan of Care SCP and new care coordination opportunities drive improvement at the beneficiary level, the Demonstration will create new relationships across primary and acute care, LTSS, and behavioral health systems. In support of Medicare- Medicare-Medicaid beneficiaries in the Demonstration, RCCOs have worked collaboratively with SEPs, CCBs, BHOs, hospitals, home health organizations, disability organizations, skilled nursing facilities, and hospice organizations to establish and test written protocols in their corresponding regions and communities. These protocols have been approved by the Demonstration’s Advisory Subcommittee and recommended to the Department for use during readiness for and implementation of the Demonstration. Reference to the protocols has been included in RCCO contract amendments. Given that the State already has achieved one of the lowest rates of institutional long term care placement in the country, the two long-term services and supports State specific demonstration measures will allow credit for maintaining or improving performance over time.