Care Needs Screening and Appropriate Follow. Up The Contractor shall ensure that Enrollees receive screenings to identify their health and functional needs as follows: 1. The Contractor shall develop, implement, and maintain procedures for completing an initial Care Needs Screening for each Enrollee and shall make best efforts to complete such screening within 90 days of the Enrollee’s Effective Date of Enrollment; 2. The Contractor’s Care Needs Screening shall: a. Be a survey-based instrument approved by EOHHS; b. Be made available to Enrollees in multiple formats including Web, print and telephone; c. Be conducted with the consent of the Enrollee; d. Include disclosures of how information will be used; e. Incorporate, at a minimum, questions: 1) On member demographics; 2) On personal health history, including chronic illness and current treatment; 3) On self-perceived health status; 4) To identify Enrollees with Special Health Care Needs; 5) To identify Enrollees’ needs for Culturally and Linguistically Appropriate Services, including but not limited to hearing and vision impairment and language preference; 6) To identify Enrollees’ needs for accessible medical diagnostic equipment; 7) To identify the Enrollee’s health concerns and goals; and 8) That specifically screen for care needs experienced by children, including evaluating characteristics of the Enrollees’ families and homes; f. As further directed by EOHHS, evaluate Enrollees’ needs for Behavioral Health-related services, including unmet needs, and including Enrollees’ appropriateness for assignment to BH CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to: 1) The Enrollee’s current use of BH Services, if any, including substance use disorder treatment services; 2) The presence of mental health diagnoses or conditions, if any; 3) The presence of any substance use disorders, if any; and 4) The Enrollee’s affiliation with any state agency that provides BH-related care management or other activities, including the Department of Mental Health (DMH) and the Bureau of Substance Abuse Services (BSAS); g. As further directed by EOHHS, evaluate Enrollees’ needs for LTSS and LTSS-related services, including unmet needs, and including Enrollees’ appropriateness for assignment to LTSS CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to: 1) Current use of MassHealth LTSS, such as: a) Adult Day Health Services; b) Adult Xxxxxx Care Services; c) Continuous Skilled Nursing Services (post-100 days of services); d) Day Habilitation Services; e) Group Adult Xxxxxx Care Services; f) Nursing Facility Services (post-100 days of services); g) Inpatient and Outpatient Chronic Disease Rehabilitation Hospital Services (post- 100 days of services); and h) Personal Care Attendant Services (including Transitional Living Program); 2) Participation in a Home and Community Based Services (HCBS) Waiver; 3) Affiliation with any state agency that provides HCBS Waiver-like services, such as those provided by the Department of Developmental Services (DDS), Executive Office of Elder Affairs (EOEA), Massachusetts Commission for the Blind (MCB), Massachusetts Commission for the Deaf and Hard of Hearing, or Massachusetts Rehabilitation Commission (MRC); 4) Need for assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs); 5) Risk for institutionalization; 6) Any other clinical presentation that indicates a potential need for LTSS care, such as an indicated need for home-based nursing; and 7) Whether the Enrollee currently is the only adult in their home environment; h. As further directed by EOHHS, evaluate Enrollees’ health-related social needs, including whether the Enrollee would benefit from receiving community services to address health-related social needs. Such services shall include but not be limited to: 1) Housing stabilization and support services; 2) Housing search and placement; 3) Utility assistance; 4) Physical activity and nutrition; and 5) Support for Enrollees who have experience of violence; i. Evaluate Enrollees’ needs for care that is Culturally and Linguistically Competent, including identifying Enrollees’ preferred languages; j. Evaluate whether an Enrollee is an Enrollee with Special Health Care Needs; and k. Otherwise identify an Enrollee’s risk factors and relevant health and functional needs, as further directed by EOHHS. 3. The Contractor shall evaluate Enrollees’ needs through means other than the Care Needs Screenings. Such means shall include but not be limited to regular analysis of available claims, encounter, and clinical data on Enrollees’ diagnoses and patterns of care; 4. The Contractor shall ensure that Enrollees receive Medically Necessary and appropriate care and follow-up based on their identified needs, including but not limited to needs identified through the Contractor’s Care Needs Screening. The Contractor shall: a. For Enrollees with identified LTSS- or BH-related needs, coordinate as appropriate with the Contractor’s CPs to fulfill the requirements of this Section 2.3.B, as described in Sections 2.3.F and 2.3.G; b. Ensure that Enrollees who are identified as having care needs as described in this Section receive assistance in accessing services to meet those needs. Such assistance shall include activities such as but not limited to: 1) Referring the Enrollees to Providers, social service agencies, or other community- based organizations that address the Enrollee’s needs, including but not limited to Medically Necessary services; 2) Providing the Enrollee with support to ensure a successful referral, including: a) Ensuring the Enrollee attends the referred appointment, including activities such as coordinating transportation assistance and following up after missed appointments; b) The Enrollee’s PCC communicating and sharing records with the Provider being referred to, as appropriate to coordinate care; and c) The Enrollee’s PCC directly introducing the Enrollee to the service Provider, if co-located, during a medical visit (i.e., a “warm hand-off”); 3) Providing information and navigation to the Enrollee regarding community providers of social services that address the Enrollee’s health-related social needs, as appropriate; 4) Providing the Enrollee with information and impartial counseling about available options; 5) Coordinating with service Providers and state agencies to improve integration of Enrollees’ care; and 6) Facilitating the transition of an Enrollee to a different level of care, setting of care, frequency of care, or provider, to better match care to the Enrollee’s indicated needs; c. Ensure that Enrollees with Special Health Care Needs are comprehensively assessed and receive a Care Plan, as described in Section 2.3.D; d. Develop, implement, and maintain policies and procedures regarding the identification of, outreach to, and assessment of Enrollees with Special Health Care Needs within the required timeframe specified in Section 2.3.D; e. Ensure that Enrollees with identified LTSS needs receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to an LTSS CP or otherwise being comprehensively assessed and receiving a Care Plan, as described in Section 2.3.D; f. Ensure that BH and LTSS CP Assigned Enrollees receive a Comprehensive Assessment and a Care Plan, as described in Section 2.3.D; g. Ensure that all Enrollees with Significant BH Needs receive appropriate services to address their care needs, as follows: 1) The Contractor shall: a) Ensure all such Enrollees receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to a BH CP, as described in Section 2.3.D; b) Work with the Contractor’s BH CPs to assist such Enrollees with in accessing appropriate services, including but not limited to providing navigation and referral, as described in Section 2.3.F; c) Ensure that Participating PCCs utilize a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for Enrollees with potential substance use disorder treatment needs as further directed by EOHHS; d) Record in each such Enrollee’s medical record appropriate information on the Enrollee’s access to care, including but not limited to information on whether each Enrollee has a Comprehensive Assessment, a Care Plan, a Care Coordinator or Clinical Care Manager assigned to their care, and sufficient access to ongoing support and treatment that meets the Enrollee’s care needs; e) Report to EOHHS on such information and on the Contractor’s success in connecting such Enrollees to appropriate levels of care, in aggregate form or as further directed by EOHHS; and f) Ensure that each such Enrollee’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164 Subparts A and E, to the extent that they are applicable; 2) Such services shall include but not be limited to services such as: a) Behavioral Health Services including inpatient, diversionary, and outpatient care; b) Substance use disorder treatment; c) Peer Supports, recovery coaches, and self-help groups; d) For Enrollees under the age of 21, Children’s Behavioral Health Initiative Services; e) Community Support Program (CSP) services, including but not limited to CSP services for the chronically homeless; and f) Services provided by other state agencies, including but not limited to DMH, DDS, DCF, and DYS; 3) This Section 2.3.B.4.g shall not be interpreted to eliminate or otherwise modify the Contractor’s other responsibilities as described in this Contract.
Appears in 2 contracts
Samples: Contract for Primary Care Accountable Care Organization Services, Contract
Care Needs Screening and Appropriate Follow. Up The Contractor shall ensure that Enrollees receive screenings to identify their health and functional needs as follows:
1. The Contractor shall develop, implement, and maintain procedures for completing an initial Care Needs Screening for each Enrollee Enrollee, and shall make best efforts to complete such screening within 90 days of the Enrollee’s Effective Date of Enrollment, including making subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful;
2. The Contractor’s Care Needs Screening shall:
a. Be a survey-based instrument approved by EOHHS;
b. Be made available to Enrollees in multiple formats including Web, print and telephone;
c. Be conducted with the consent of the Enrollee;
d. Include disclosures of how information will be used;
e. IncorporateIn addition to the other requirements of this Section, incorporate, at a minimum, questions:
1) On The National Committee for Quality Assurance (NCQA) Member Connections (MEM) 1 Health Appraisals Element A standards including but not limited to questions on member demographics;
2) On , personal health history, including chronic illness and current treatment;
3) On self-; and self- perceived health status;
42) To Questions to identify Enrollees with Special Health Care Needs;
53) To Questions to identify Enrollees’ needs for Culturally and Linguistically Appropriate Services, Services including but not limited to hearing and vision impairment and language preference;
64) To Questions to identify Enrollees’ needs for accessible medical and diagnostic equipment;
75) To Questions to identify the Enrollee’s health concerns and goals; and
8) That 6) Questions that specifically screen for care needs experienced by children, including evaluating characteristics of the Enrollees’ families and homes;
f. As further directed by EOHHS, evaluate Enrollees’ needs for Behavioral Health-Health- related services, including unmet needs, needs and including Enrollees’ appropriateness for assignment to BH CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to:
1) The Enrollee’s current use of BH Services, if any, including substance use disorder treatment services;
2) The presence of mental health diagnoses or conditions, if any;
3) The presence of any substance use disorders, if any; and
4) The Enrollee’s affiliation with any state agency that provides BH-related care management or other activities, including the Department of Mental Health (DMH) and the Bureau of Substance Abuse Services (BSAS);
g. As further directed by EOHHS, evaluate Enrollees’ needs for LTSS and LTSS-LTSS- related services, including unmet needs, needs and including Enrollees’ appropriateness for assignment to LTSS CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as as, but not limited to:
1) Current use of MassHealth services that could be reasonably viewed as LTSS, such as:
a) Adult Day Health Services;
b) Adult Xxxxxx Care Services;
c) Continuous Skilled Nursing Services (post-100 days of services);
d) Day Habilitation Services;
e) Group Adult Xxxxxx Care Services;
f) Nursing Facility Services (post-100 days of services);
g) Inpatient and Outpatient Chronic Disease Rehabilitation Hospital Services (post- 100 post-100 days of services); and
h) Personal Care Attendant Services (including Transitional Living Program);.
2) Participation in a Home and Community Based Services (HCBS) Waiver;
3) Affiliation with any state agency that provides HCBS Waiver-like services, such as those provided by the Department of Developmental Services (DDS), Executive Office of Elder Affairs (EOEA), Massachusetts Commission for the Blind (MCB), Massachusetts Commission for the Deaf and Hard of Hearing, or Massachusetts Rehabilitation Commission (MRC);
4) Need for assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs);
5) Risk for institutionalization;
6) Any other clinical presentation that indicates a potential need for LTSS care, such as an indicated need necessity for home-based nursing; and
7) Whether the Enrollee currently is the only adult in their home environment;.
h. As further directed by EOHHS, evaluate Enrollees’ health-related social needs, including whether the Enrollee would benefit from receiving community services to address health-related social needs. Such services shall include but not be limited to:
1) Housing stabilization and support services;
2) Housing search and placement;
3) Utility assistance;
4) Physical activity and nutrition; and
5) Support for Enrollees who have experience of violence;.
i. Evaluate Enrollees’ needs for care that is Culturally and Linguistically Competent, including identifying Enrollees’ preferred languages;
j. Evaluate whether an Enrollee is an Enrollee with Special Health Care Needs; and
k. Otherwise identify an Enrollee’s risk factors and relevant health and functional needs, as further directed by EOHHS.;
3. The Contractor shall otherwise evaluate Enrollees’ needs through means other than the Care Needs Screenings. Such means shall include but not be limited to regular analysis of available claims, encounterEncounter Data, and clinical data on Enrollees’ diagnoses and patterns of care;
4. The Contractor shall ensure that Enrollees receive Medically Necessary and appropriate care and follow-up based on their identified needsneeds through any assessment or screening, including but not limited to needs identified through the Contractor’s Care Needs Screeningthose performed pursuant to this Section. The Contractor shall:
a. For Enrollees with identified LTSS- or BH-related needs, coordinate as appropriate with the Contractor’s CPs to fulfill fulfil the requirements of this Section 2.3.BSection, as described in Sections 2.3.F 2.5.F and 2.3.G2.5.G;
b. Ensure that Enrollees who are identified as having care needs as described in this Section receive assistance in accessing services to meet those needs. Such assistance shall include activities such as but not limited to:
1) Referring the Enrollees Enrollee to Providersproviders, social service agencies, or other community- community-based organizations that address the Enrollee’s needs, including but not limited to Medically Necessary services;
2) Providing the Enrollee with support to ensure a successful referral, including:
a) Ensuring the Enrollee attends the referred appointment, including activities such as coordinating transportation assistance and following up after missed appointments;
b) The Enrollee’s PCC PCP communicating and sharing records with the Provider provider being referred to, as appropriate to coordinate care; and
c) The Enrollee’s PCC PCP directly introducing the Enrollee to the service Providerprovider, if co-located, during a medical visit (i.e., a “warm hand-off”);.
3) Providing information and navigation to the Enrollee regarding community providers of social services that address the Enrollee’s health-related social needs, as appropriate;
4) Providing the Enrollee with information and providing impartial counseling about available options;
5) Coordinating with service Providers providers and state agencies to improve integration of Enrollees’ care; and
6) Facilitating the transition of an Enrollee to a different level of care, setting of care, frequency of care, or provider, to better match care to the Enrollee’s indicated needs;
c. Ensure that Enrollees with Special Health Care Needs are comprehensively assessed and receive a Care Plan, as described in Section 2.3.D2.5.D;
d. DevelopThe Contractor shall develop, implement, and maintain policies and procedures regarding the identification of, outreach to, and assessment of Enrollees with Special Health Care Needs within the required timeframe specified in Section 2.3.D2.5.D;
e. Ensure that Enrollees with identified LTSS needs receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to an LTSS CP or otherwise being comprehensively assessed and receiving a Care Plan, as described in Section 2.3.D2.5;
f. Ensure that BH and LTSS CP CP-Assigned Enrollees receive a Comprehensive Assessment and a Care Plan, as described in Section 2.3.D2.5;
g. Ensure that all Enrollees with Significant BH Needs Needs, as further defined by EOHHS, receive appropriate services to address their care needs, as follows:
1) The Contractor shall:
a) Ensure all such Enrollees receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to a BH CP, as described in Section 2.3.D2.5.D;
b) Work with the Contractor’s BH CPs to assist such Enrollees with in accessing appropriate services, including but not limited to providing navigation and referral, as described in Section 2.3.F2.5.F;
c) Ensure that Participating PCCs providers utilize a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for Enrollees with potential substance use disorder treatment needs Enrollees, as appropriate and as further directed specified by EOHHS;
d) Record in each such Enrollee’s medical record appropriate information on the Enrollee’s access to care, including but not limited to information on whether each Enrollee has a Comprehensive Assessment, a Care Plan, a Care Coordinator or Clinical Care Manager assigned to their care, and sufficient access to ongoing support and treatment that meets the Enrollee’s care needs;
e) Report to EOHHS on such information and on the Contractor’s success in connecting such Enrollees to appropriate levels of care, in aggregate form or as further directed by EOHHS; and
f) Ensure that each such Enrollee’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164 Subparts A and E, to the extent that they are as applicable;
2) Such services shall include but not be limited to services such as:
a) Behavioral Health Services health services including inpatient, diversionary, and outpatient care;
b) Substance use disorder treatment;
c) Peer Supports, recovery coachesRecovery Coaches, and self-help groups;
d) For Enrollees under the age of 21, services under the Children’s Behavioral Health Initiative ServicesInitiative;
e) Community Support Program (CSP) services, including but not limited to CSP services for the chronically homeless; and
f) Services provided by other state agencies, including but not limited to DMH, DDS, DCF, and DYS;
3) This Section 2.3.B.4.g h. The Contractor shall not be interpreted to eliminate or otherwise modify the Contractor’s other responsibilities ensure that certain Enrollees receive BH clinical assessment and treatment planning as described in this Contract.Section 2.8.D;
Appears in 2 contracts
Samples: Accountable Care Partnership Plan Contract, Accountable Care Partnership Plan Contract
Care Needs Screening and Appropriate Follow. Up The Contractor shall ensure that Enrollees receive screenings to identify their health and functional needs as follows:
1. The Contractor shall develop, implement, and maintain procedures for completing an initial Care Needs Screening for each Enrollee Enrollee, and shall make best efforts to complete such screening within 90 days of the Enrollee’s Effective Date of Enrollment;
2. The Contractor’s Care Needs Screening shall:
a. Be a survey-based instrument approved by EOHHS;
b. Be made available to Enrollees in multiple formats including Web, print and telephone;
c. Be conducted with the consent of the Enrollee;
d. Include disclosures of how information will be used;
e. IncorporateIn addition to the other requirements of this Section, incorporate, at a minimum, questions:
1) On The National Committee for Quality Assurance (NCQA) Member Connections (MEM) 1 Health Appraisals Element A standards including but not limited to questions on member demographics;
2) On , personal health history, including chronic illness and current treatment;
3) On ; and self-perceived health status;
42) To Questions to identify Enrollees with Special Health Care Needs;
53) To Questions to identify Enrollees’ needs for Culturally and Linguistically Appropriate Services, Services including but not limited to hearing and vision impairment and language preference;
64) To Questions to identify Enrollees’ needs for accessible medical and diagnostic equipment;
75) To Questions to identify the Enrollee’s health concerns and goals; and
8) That 6) Questions that specifically screen for care needs experienced by children, including evaluating characteristics of the Enrollees’ families and homes;
f. As further directed by EOHHS, evaluate Enrollees’ needs for Behavioral Health-related services, including unmet needs, needs and including Enrollees’ appropriateness for assignment to BH CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to:
1) The Enrollee’s current use of BH Services, if any, including substance use disorder treatment services;
2) The presence of mental health diagnoses or conditions, if any;
3) The presence of any substance use disorders, if any; and
4) The Enrollee’s affiliation with any state agency that provides BH-BH- related care management or other activities, including the Department of Mental Health (DMH) and the Bureau of Substance Abuse Services (BSAS);
g. As further directed by EOHHS, evaluate Enrollees’ needs for LTSS and LTSS-related services, including unmet needs, needs and including Enrollees’ appropriateness for assignment to LTSS CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as as, but not limited to:
1) Current use of MassHealth services that could be reasonably viewed as LTSS, such as:
a) Adult Day Health Services;
b) Adult Xxxxxx Care Services;
c) Continuous Skilled Nursing Services (post-100 days of services);
d) Day Habilitation Services;
e) Group Adult Xxxxxx Care Services;
f) Nursing Facility Services (post-100 days of services);
g) Inpatient and Outpatient Chronic Disease Rehabilitation Hospital Services (post- 100 post-100 days of services); and
h) Personal Care Attendant Services (including Transitional Living Program);.
2) Participation in a Home and Community Based Services (HCBS) Waiver;
3) Affiliation with any state agency that provides HCBS Waiver-like services, such as those provided by the Department of Developmental Services (DDS), Executive Office of Elder Affairs (EOEA), Massachusetts Commission for the Blind (MCB), Massachusetts Commission for the Deaf and Hard of Hearing, or Massachusetts Rehabilitation Commission (MRC);
4) Need for assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs);
5) Risk for institutionalization;
6) Any other clinical presentation that indicates a potential need for LTSS care, such as an indicated need necessity for home-based nursing; and
7) Whether the Enrollee currently is the only adult in their home environment;.
h. As further directed by EOHHSEOHHX, evaluate xxaluate Enrollees’ health-related social needs, including whether the Enrollee would benefit from receiving community services to address health-related social needs. Such services shall include but not be limited to:
1) Housing stabilization and support services;
2) Housing search and placement;
3) Utility assistance;
4) Physical activity and nutrition; and
5) Support for Enrollees who have experience of violence;.
i. Evaluate Enrollees’ needs for care that is Culturally and Linguistically Competent, including identifying Enrollees’ preferred languages;
j. Evaluate whether an Enrollee is an Enrollee with Special Health Care Needs; and
k. Otherwise identify an Enrollee’s risk factors and relevant health and functional needs, as further directed by EOHHS.;
3. The Contractor shall otherwise evaluate Enrollees’ needs through means other than the Care Needs Screenings. Such means shall include but not be limited to regular analysis of available claims, encounterEncounter Data, and clinical data on Enrollees’ diagnoses and patterns of care;
4. The Contractor shall ensure that Enrollees receive Medically Necessary and appropriate care and follow-up based on their identified needsneeds through any assessment or screening, including but not limited to needs identified through the Contractor’s Care Needs Screeningthose performed pursuant to this Section. The Contractor shall:
a. For Enrollees with identified LTSS- or BH-related needs, coordinate as appropriate with the Contractor’s CPs to fulfill fulfil the requirements of this Section 2.3.BSection, as described in Sections 2.3.F 2.5.F and 2.3.G2.5.G;
b. Ensure that Enrollees who are identified as having care needs as described in this Section receive assistance in accessing services to meet those needs. Such assistance shall include activities such as but not limited to:
1) Referring the Enrollees Enrollee to Providersproviders, social service agencies, or other community- community-based organizations that address the Enrollee’s needs, including but not limited to Medically Necessary services;
2) Providing the Enrollee with support to ensure a successful referral, including:
a) Ensuring the Enrollee attends the referred appointment, including activities such as coordinating transportation assistance and following up after missed appointments;
b) The Enrollee’s PCC PCP communicating and sharing records with the Provider provider being referred to, as appropriate to coordinate care; and
c) The Enrollee’s PCC PCP directly introducing the Enrollee to the service Providerprovider, if co-located, during a medical visit (i.e., a “warm hand-off”);.
3) Providing information and navigation to the Enrollee regarding community providers of social services that address the Enrollee’s health-related social needs, as appropriate;
4) Providing the Enrollee with information and providing impartial counseling about available options;
5) Coordinating with service Providers providers and state agencies to improve integration of Enrollees’ care; and
6) Facilitating the transition of an Enrollee to a different level of care, setting of care, frequency of care, or provider, to better match care to the Enrollee’s indicated needs;
c. Ensure that Enrollees with Special Health Care Needs are comprehensively assessed and receive a Care Plan, as described in Section 2.3.D2.5.D;
d. DevelopThe Contractor shall develop, implement, and maintain policies and procedures regarding the identification of, outreach to, and assessment of Enrollees with Special Health Care Needs within the required timeframe specified in Section 2.3.D2.5.D;
e. Ensure that Enrollees with identified LTSS needs receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to an LTSS CP or otherwise being comprehensively assessed and receiving a Care Plan, as described in Section 2.3.D2.5;
f. Ensure that BH and LTSS CP CP-Assigned Enrollees receive a Comprehensive Assessment and a Care Plan, as described in Section 2.3.D2.5;
g. Ensure that all Enrollees with Significant BH Needs Needs, as further defined by EOHHS, receive appropriate services to address their care needs, as follows:
1) The Contractor shall:
a) Ensure all such Enrollees receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to a BH CP, as described in Section 2.3.D2.5.D;
b) Work with the Contractor’s BH CPs to assist such Enrollees with in accessing appropriate services, including but not limited to providing navigation and referral, as described in Section 2.3.F2.5.F;
c) Ensure that Participating PCCs providers utilize a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for Enrollees with potential substance use disorder treatment needs as further directed by EOHHS;
d) Record in each such Enrollee’s medical record appropriate information on the Enrollee’s access to care, including but not limited to information on whether each Enrollee has a Comprehensive Assessment, a Care Plan, a Care Coordinator or Clinical Care Manager assigned to their care, and sufficient access to ongoing support and treatment that meets the Enrollee’s care needs;
e) Report to EOHHS on such information and on the Contractor’s success in connecting such Enrollees to appropriate levels of care, in aggregate form or as further directed by EOHHS; and
f) Ensure that each such Enrollee’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164 Subparts A and E, to the extent that they are as applicable;
2) Such services shall include but not be limited to services such as:
a) Behavioral Health Services health services including inpatient, diversionary, and outpatient care;
b) Substance use disorder treatment;
c) Peer Supports, recovery coaches, and self-help groups;
d) For Enrollees under the age of 21, services under the Children’s Behavioral Health Initiative ServicesInitiative;
e) Community Support Program (CSP) services, including but not limited to CSP services for the chronically homeless; and
f) Services provided by other state agencies, including but not limited to DMH, DDS, DCF, and DYS;
3) This Section 2.3.B.4.g h. The Contractor shall not be interpreted to eliminate or otherwise modify the Contractor’s other responsibilities ensure that certain Enrollees receive BH clinical assessment and treatment planning as described in this Contract.Section 2.8.D;
Appears in 1 contract
Care Needs Screening and Appropriate Follow. Up The Contractor shall ensure that Enrollees receive screenings to identify their health and functional needs as follows:
1. The Contractor shall develop, implement, and maintain procedures for completing an initial Care Needs Screening for each Enrollee and shall make best efforts to complete such screening within 90 days of the Enrollee’s Effective Date of Enrollment;
2. The Contractor’s Care Needs Screening shall:
a. Be a survey-based instrument approved by EOHHS;
b. Be made available to Enrollees in multiple formats including Web, print and telephone;
c. Be conducted with the consent of the Enrollee;
d. Include disclosures of how information will be used;
e. Incorporate, at a minimum, questions:
1) On member demographics;
2) On personal health history, including chronic illness and current treatment;
3) On self-perceived health status;
4) To identify Enrollees with Special Health Care Needs;
5) To identify Enrollees’ needs for Culturally and Linguistically Appropriate Services, including but not limited to hearing and vision impairment and language preference;
6) To identify Enrollees’ needs for accessible medical diagnostic equipment;
7) To identify the Enrollee’s health concerns and goals; and
8) That specifically screen for care needs experienced by children, including evaluating characteristics of the Enrollees’ families and homes;
f. As further directed by EOHHS, evaluate Enrollees’ needs for Behavioral Health-related services, including unmet needs, and including Enrollees’ appropriateness for assignment to BH CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to:
1) The Enrollee’s current use of BH Services, if any, including substance use disorder treatment services;
2) The presence of mental health diagnoses or conditions, if any;
3) The presence of any substance use disorders, if any; and
4) The Enrollee’s affiliation with any state agency that provides BH-related care management or other activities, including the Department of Mental Health (DMH) and the Bureau of Substance Abuse Services (BSAS);
g. As further directed by EOHHS, evaluate Enrollees’ needs for LTSS and LTSS-related services, including unmet needs, and including Enrollees’ appropriateness for assignment to LTSS CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to:
1) Current use of MassHealth LTSS, such as:
a) Adult Day Health Services;
b) Adult Xxxxxx Care Services;
c) Continuous Skilled Nursing Services (post-100 days of services);
d) Day Habilitation Services;
e) Group Adult Xxxxxx Care Services;
f) Nursing Facility Services (post-100 days of services);
g) Inpatient and Outpatient Chronic Disease Rehabilitation Hospital Services (post- 100 days of services); and
h) Personal Care Attendant Services (including Transitional Living Program);
2) Participation in a Home and Community Based Services (HCBS) Waiver;
3) Affiliation with any state agency that provides HCBS Waiver-like services, such as those provided by the Department of Developmental Services (DDS), Executive Office of Elder Affairs (EOEA), Massachusetts Commission for the Blind (MCB), Massachusetts Commission for the Deaf and Hard of Hearing, or Massachusetts Rehabilitation Commission (MRC);
4) Need for assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs);
5) Risk for institutionalization;
6) Any other clinical presentation that indicates a potential need for LTSS care, such as an indicated need for home-based nursing; and
7) Whether the Enrollee currently is the only adult in their home environment;
h. As further directed by EOHHSXXXXX, evaluate Enrollees’ health-related social needs, including whether the Enrollee would benefit from receiving community services to address health-related social needs. Such services shall include but not be limited to:
1) Housing stabilization and support services;
2) Housing search and placement;
3) Utility assistance;
4) Physical activity and nutrition; and
5) Support for Enrollees who have experience of violence;
i. Evaluate Enrollees’ needs for care that is Culturally and Linguistically Competent, including identifying Enrollees’ preferred languages;
j. Evaluate whether an Enrollee is an Enrollee with Special Health Care Needs; and
k. Otherwise identify an Enrollee’s risk factors and relevant health and functional needs, as further directed by EOHHSXXXXX.
3. The Contractor shall evaluate Enrollees’ needs through means other than the Care Needs Screenings. Such means shall include but not be limited to regular analysis of available claims, encounter, and clinical data on Enrollees’ diagnoses and patterns of care;
4. The Contractor shall ensure that Enrollees receive Medically Necessary and appropriate care and follow-up based on their identified needs, including but not limited to needs identified through the Contractor’s Care Needs Screening. The Contractor shall:
a. For Enrollees with identified LTSS- or BH-related needs, coordinate as appropriate with the Contractor’s CPs to fulfill the requirements of this Section 2.3.B, as described in Sections 2.3.F and 2.3.G;
b. Ensure that Enrollees who are identified as having care needs as described in this Section receive assistance in accessing services to meet those needs. Such assistance shall include activities such as but not limited to:
1) Referring the Enrollees to Providers, social service agencies, or other community- based organizations that address the Enrollee’s needs, including but not limited to Medically Necessary services;
2) Providing the Enrollee with support to ensure a successful referral, including:
a) Ensuring the Enrollee attends the referred appointment, including activities such as coordinating transportation assistance and following up after missed appointments;
b) The Enrollee’s PCC communicating and sharing records with the Provider being referred to, as appropriate to coordinate care; and
c) The Enrollee’s PCC directly introducing the Enrollee to the service Provider, if co-located, during a medical visit (i.e., a “warm hand-off”);
3) Providing information and navigation to the Enrollee regarding community providers of social services that address the Enrollee’s health-related social needs, as appropriate;
4) Providing the Enrollee with information and impartial counseling about available options;
5) Coordinating with service Providers and state agencies to improve integration of Enrollees’ care; and
6) Facilitating the transition of an Enrollee to a different level of care, setting of care, frequency of care, or provider, to better match care to the Enrollee’s indicated needs;
c. Ensure that Enrollees with Special Health Care Needs are comprehensively assessed and receive a Care Plan, as described in Section 2.3.D;
d. Develop, implement, and maintain policies and procedures regarding the identification of, outreach to, and assessment of Enrollees with Special Health Care Needs within the required timeframe specified in Section 2.3.D;
e. Ensure that Enrollees with identified LTSS needs receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to an LTSS CP or otherwise being comprehensively assessed and receiving a Care Plan, as described in Section 2.3.D;
f. Ensure that BH and LTSS CP Assigned Enrollees receive a Comprehensive Assessment and a Care Plan, as described in Section 2.3.D;
g. Ensure that all Enrollees with Significant BH Needs receive appropriate services to address their care needs, as follows:
1) The Contractor shall:
a) Ensure all such Enrollees receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to a BH CP, as described in Section 2.3.D;
b) Work with the Contractor’s BH CPs to assist such Enrollees with in accessing appropriate services, including but not limited to providing navigation and referral, as described in Section 2.3.F;
c) Ensure that Participating PCCs utilize a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for Enrollees with potential substance use disorder treatment needs as further directed by EOHHS;
d) Record in each such Enrollee’s medical record appropriate information on the Enrollee’s access to care, including but not limited to information on whether each Enrollee has a Comprehensive Assessment, a Care Plan, a Care Coordinator or Clinical Care Manager assigned to their care, and sufficient access to ongoing support and treatment that meets the Enrollee’s care needs;
e) Report to EOHHS on such information and on the Contractor’s success in connecting such Enrollees to appropriate levels of care, in aggregate form or as further directed by EOHHS; and
f) Ensure that each such Enrollee’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164 Subparts A and E, to the extent that they are applicable;
2) Such services shall include but not be limited to services such as:
a) Behavioral Health Services including inpatient, diversionary, and outpatient care;
b) Substance use disorder treatment;
c) Peer Supports, recovery coaches, and self-help groups;
d) For Enrollees under the age of 21, Children’s Behavioral Health Initiative Services;
e) Community Support Program (CSP) services, including but not limited to CSP services for the chronically homeless; and
f) Services provided by other state agencies, including but not limited to DMH, DDS, DCF, and DYS;
3) This Section 2.3.B.4.g shall not be interpreted to eliminate or otherwise modify the Contractor’s other responsibilities as described in this Contract.
Appears in 1 contract
Samples: Contract for Primary Care Accountable Care Organization Services
Care Needs Screening and Appropriate Follow. Up The Contractor shall ensure that Enrollees receive screenings to identify their health and functional needs as follows:
1. The Contractor shall develop, implement, and maintain procedures for completing completing, an initial Care Needs Screening for each Enrollee Enrollee, and shall make best efforts to complete such screening within 90 days of the Enrollee’s Effective Date of Enrollment;
2. The Contractor’s Care Needs Screening shall:
a. Be a survey-based instrument approved by EOHHS;
b. Be made available to Enrollees in multiple formats including Web, print and telephone;
c. Be conducted with the consent of the Enrollee;
d. Include disclosures of how information will be used;
e. IncorporateIn addition to the other requirements of this Section, incorporate, at a minimum, questions:
1) On The National Committee for Quality Assurance (NCQA) Member Connections (MEM) 1 Health Appraisals Element A standards including but not limited to questions on member demographics;
2) On , personal health history, including chronic illness and current treatment;
3) On ; and self-perceived health status;
42) To Questions to identify Enrollees with Special Health Care Needs;
53) To Questions to identify Enrollees’ needs for Culturally and Linguistically Appropriate Services, Services including but not limited to hearing and vision impairment and language preference;
64) To Questions to identify Enrollees’ needs for accessible medical and diagnostic equipment;
75) To Questions to identify the Enrollee’s health concerns and goals; and
8) That 6) Questions that specifically screen for care needs experienced by children, including evaluating characteristics of the Enrollees’ families and homes;
f. As further directed by EOHHS, evaluate Enrollees’ needs for Behavioral Health-related services, including unmet needs, needs and including Enrollees’ appropriateness for assignment to BH CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as but not limited to:
1) The Enrollee’s current use of BH Services, if any, including substance use disorder treatment services;
2) The presence of mental health diagnoses or conditions, if any;
3) The presence of any substance use disorders, if any; and
4) The Enrollee’s affiliation with any state agency that provides BH-related care management or other activities, including the Department of Mental Health (DMH) and the Bureau of Substance Abuse Services (BSAS);
g. As further directed by EOHHS, evaluate Enrollees’ needs for LTSS and LTSS-related services, including unmet needs, needs and including Enrollees’ appropriateness for assignment to LTSS CPs as further specified by EOHHS. The Contractor’s Care Needs Screening shall evaluate characteristics such as as, but not limited to:
1) Current use of MassHealth services that could be reasonably viewed as LTSS, such as:
a) Adult Day Health Services;
b) Adult Xxxxxx Care Services;
c) Continuous Skilled Nursing Services (post-100 days of services);
d) Day Habilitation Services;
e) Group Adult Xxxxxx Care Services;
f) Nursing Facility Services (post-100 days of services);
g) Inpatient and Outpatient Chronic Disease Rehabilitation Hospital Services (post- 100 days of services); and
h) Personal Care Attendant Services (including Transitional Living Program);.
2) Participation in a Home and Community Based Services (HCBS) Waiver;
3) Affiliation with any state agency that provides HCBS Waiver-like services, such as those provided by the Department of Developmental Services (DDS), Executive Office of Elder Affairs (EOEA), Massachusetts Commission for the Blind (MCB), Massachusetts Commission for the Deaf and Hard of Hearing, or Massachusetts Rehabilitation Commission (MRC);
4) Need for assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs);
5) Risk for institutionalization;
6) Any other clinical presentation that indicates a potential need for LTSS care, such as an indicated need necessity for home-based nursing; and
7) Whether the Enrollee currently is the only adult in their home environment;.
h. As further directed by EOHHS, evaluate Enrollees’ health-related social needs, including whether the Enrollee would benefit from receiving community services to address health-related social needs. Such services shall include but not be limited to:
1) Housing stabilization and support services;
2) Housing search and placement;
3) Utility assistance;
4) Physical activity and nutrition; and
5) Support for Enrollees who have experience of violence;.
i. Evaluate Enrollees’ needs for care that is Culturally and Linguistically Competent, including identifying Enrollees’ preferred languages;
j. Evaluate whether an Enrollee is an Enrollee with Special Health Care Needs; and
k. Otherwise identify an Enrollee’s risk factors and relevant health and functional needs, as further directed by EOHHS.
3. The Contractor shall otherwise evaluate Enrollees’ needs through means other than the Care Needs Screenings. Such means shall include but not be limited to regular analysis of available claims, encounterEncounter Data, and clinical data on Enrollees’ diagnoses and patterns of care;
4. The Contractor shall ensure that Enrollees receive Medically Necessary and appropriate care and follow-up based on their identified needsneeds through any assessment or screening, including but not limited to needs identified through the Contractor’s Care Needs Screeningthose performed pursuant to this Section. The Contractor shall:
a. For Enrollees with identified LTSS- or BH-related needs, coordinate as appropriate with the Contractor’s CPs to fulfill fulfil the requirements of this Section 2.3.BSection, as described in Sections 2.3.F and 2.3.G;
b. Ensure that Enrollees who are identified as having care needs as described in this Section receive assistance in accessing services to meet those needs. Such assistance shall include activities such as but not limited to:
1) Referring the Enrollees to Providers, social service agencies, or other community- based organizations that address the Enrollee’s needs, including but not limited to Medically Necessary services;
2) Providing the Enrollee with support to ensure a successful referral, including:
a) Ensuring the Enrollee attends the referred appointment, including activities such as coordinating transportation assistance and following up after missed appointments;
b) The Enrollee’s PCC communicating and sharing records with the Provider being referred to, as appropriate to coordinate care; and
c) The Enrollee’s PCC directly introducing the Enrollee to the service Provider, if co-located, during a medical visit (i.e., a “warm hand-off”);
3) Providing information and navigation to the Enrollee regarding community providers of social services that address the Enrollee’s health-related social needs, as appropriate;
4) Providing the Enrollee with information and impartial counseling about available options;
5) Coordinating with service Providers and state agencies to improve integration of Enrollees’ care; and
6) Facilitating the transition of an Enrollee to a different level of care, setting of care, frequency of care, or provider, to better match care to the Enrollee’s indicated needs;
c. Ensure that Enrollees with Special Health Care Needs are comprehensively assessed and receive a Care Plan, as described in Section 2.3.D;
d. Develop, implement, and maintain policies and procedures regarding the identification of, outreach to, and assessment of Enrollees with Special Health Care Needs within the required timeframe specified in Section 2.3.D;
e. Ensure that Enrollees with identified LTSS needs receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to an LTSS CP or otherwise being comprehensively assessed and receiving a Care Plan, as described in Section 2.3.D;
f. Ensure that BH and LTSS CP Assigned Enrollees receive a Comprehensive Assessment and a Care Plan, as described in Section 2.3.D;
g. Ensure that all Enrollees with Significant BH Needs receive appropriate services to address their care needs, as follows:
1) The Contractor shall:
a) Ensure all such Enrollees receive appropriate services and referrals to address their care needs, which may include for certain Enrollees referral to a BH CP, as described in Section 2.3.D;
b) Work with the Contractor’s BH CPs to assist such Enrollees with in accessing appropriate services, including but not limited to providing navigation and referral, as described in Section 2.3.F;
c) Ensure that Participating PCCs utilize a Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for Enrollees with potential substance use disorder treatment needs as further directed by EOHHS;
d) Record in each such Enrollee’s medical record appropriate information on the Enrollee’s access to care, including but not limited to information on whether each Enrollee has a Comprehensive Assessment, a Care Plan, a Care Coordinator or Clinical Care Manager assigned to their care, and sufficient access to ongoing support and treatment that meets the Enrollee’s care needs;
e) Report to EOHHS on such information and on the Contractor’s success in connecting such Enrollees to appropriate levels of care, in aggregate form or as further directed by EOHHS; and
f) Ensure that each such Enrollee’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164 Subparts A and E, to the extent that they are applicable;
2) Such services shall include but not be limited to services such as:
a) Behavioral Health Services including inpatient, diversionary, and outpatient care;
b) Substance use disorder treatment;
c) Peer Supports, recovery coaches, and self-help groups;
d) For Enrollees under the age of 21, Children’s Behavioral Health Initiative Services;
e) Community Support Program (CSP) services, including but not limited to CSP services for the chronically homeless; and
f) Services provided by other state agencies, including but not limited to DMH, DDS, DCF, and DYS;
3) This Section 2.3.B.4.g shall not be interpreted to eliminate or otherwise modify the Contractor’s other responsibilities as described in this Contract.Sections
Appears in 1 contract
