Common use of Care Plan Development Clause in Contracts

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, approach and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, plan and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v438.208(c)(3)(iii)-(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- re-assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v438.208(c)(3)(iii)-(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectivesobjectives , goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v438.208(c)(3)(iii)-(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization hospitalizati on or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- re-assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v438.208(c)(3)(iii)-(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ • Clinical history and pertinent family history; ▪ • Diagnosis(es); ▪ • Functional and/or cognitive status; ▪ • Medical Equipment and Medical Equipment Suppliers; ▪ • Immediate service needs; ▪ • Use of services not covered by the program; ▪ • Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ • Barriers to care (i.e. language, transportation, etc.); ▪ • PMP, if applicable; ▪ • Care/case manager from a service delivery system, for members with one; ▪ • Psychosocial support resources; ▪ • Local community resources; ▪ • Family member/caregiver/ facilitator resources and contact information; ▪ • Behavioral health status; ▪ • Intensity of services; ▪ • Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ • Member self-management goals; ▪ • Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ • Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ • Key milestones towards meeting short-term and long-term goals and objectives; ▪ • Planned interventions and contacts with member, providers and/or service delivery system; and ▪ • Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- re-assess and evaluate members, minimally including: ▪ • Pain; ▪ • Trouble sleeping; ▪ • Anxiety / depression; ▪ • Medications – poly-pharmacy and gaps in prescription refills; ▪ • Skin; ▪ • Bowel / bladder; ▪ • Transitions; ▪ • Health Maintenance – preventive care; ▪ • Health Maintenance – chronic disease management; ▪ • Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v438.208(c)(3)(iii)-(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activitiesac tivities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process, developed in accordance with any applicable State quality assurance and utilization review standards. The member or guardian must sign off on the care plan and the plan must be approved by the Contractor in a timely manner per 42 CFR 438.208(c)(3)(iii) -(v438.208(c)(3)(iii)-(v). All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure sec ure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum: ▪ Clinical history and pertinent family history; ▪ Diagnosis(es); ▪ Functional and/or cognitive status; ▪ Medical Equipment and Medical Equipment Suppliers; ▪ Immediate service needs; ▪ Use of services not covered by the program; ▪ Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services; ▪ Barriers to care (i.e. language, transportation, etc.); ▪ PMP, if applicable; ▪ Care/case manager from a service delivery system, for members with one; ▪ Psychosocial support resources; ▪ Local community resources; ▪ Family member/caregiver/ facilitator resources and contact information; ▪ Behavioral health status; ▪ Intensity of services; ▪ Assigned case coordinator for disease management, care management, complex case management, or RCP; ▪ Member self-management goals; ▪ Clearly identified, member-centered, and measurable long-term goals and objectives; ▪ Clearly identified, member-centered, and measurable short-term goals and objectives; ▪ Key milestones towards meeting short-term and long-term goals and objectives; ▪ Planned interventions and contacts with member, providers and/or service delivery system; and ▪ Assessment of progress, including input from family, if appropriate. The Contractor will have standard protocols in place to assess, plan, implement, re- assess and evaluate members, minimally including: ▪ Pain; ▪ Trouble sleeping; ▪ Anxiety / depression; ▪ Medications – poly-pharmacy and gaps in prescription refills; ▪ Skin; ▪ Bowel / bladder; ▪ Transitions; ▪ Health Maintenance – preventive care; ▪ Health Maintenance – chronic disease management; ▪ Mobility;