Complex Case Management Care Plans. Complex case management services are defined by multiple medical needs, high risk issues such as significant deterioration in health status or ongoing lack of self-management skills due to personal issues, cognitive impairment, mental illness, lack of social supports, or multiple co-morbidities. Complex case management care plans will include all elements of disease management and care management, as well as higher levels of support. The Medical Director shall be available to consult with the clinicians on the case management team as needed to develop the care plans for high-risk cases. The Contractor will use a multi-disciplinary team skilled in nursing, social work and behavioral health, with knowledge of local community resources to implement protocol-driven care modules for members. Care plans will delineate the frequency and mode of contacts with members, minimally monthly. Care plans will incorporate additional expertise as needed based on the person’s health conditions, disabilities, pharmacy, and other urgent management needs. Care plans should anticipate volatile healthcare needs, including a need for immediate respite, medical advice or home health care. Home health care is defined as limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services (see also: 42 CFR § 440.70). Care plans should foresee possible crisis situations where immediate additional support is needed to prevent hospitalizations, long-term care or poor outcomes. The Contractor shall manage care for these members, including after business hours. The Contractor will provide complex case management through consultation services with the PMP (if applicable) and other providers to facilitate communication, engaging providers, maximizing the providers’ ability to manage disease, minimizing providers’ use of unnecessary referrals and reducing the need for hospitalization and ER utilization. Care plans for complex case management services must include a schedule for contact with the PMP (if applicable) and other providers. In crisis situations, contact with the member, PMP (if applicable) and other providers is expected to be immediate, frequent and intense and not less than monthly. The Contractor will engage the member’s PMP (if applicable) and other s...
Complex Case Management Care Plans. Complex case management services are defined by multiple medical needs, high risk issues such as significant deterioration in health status or ongoing lack of self- management skills due to personal issues, cognitive impairment, mental illness, lack of social supports, or multiple co-morbidities. Complex case management care plans will include all elements of disease management and care management, as well as higher levels of support. The Contractor will use a multi-disciplinary team skilled in nursing, social work and behavioral health, with knowledge of local community resources to implement protocol- driven care modules for members. Care plans will delineate the frequency and mode of contacts with members, minimally monthly. Care plans will incorporate additional expertise as needed based on the person’s health conditions, disabilities, pharmacy, and other urgent management needs. Care plans should anticipate volatile healthcare needs, including a need for immediate respite, medical advice or home health care. Care plans should foresee possible crisis situations where immediate additional support is needed to prevent hospitalizations, long- term care or poor outcomes. Respondents must describe how they would manage care for these members, including after business hours. The Contractor will provide complex case management through consultation services with the PMP (if applicable) and other providers to facilitate communication, engaging providers, maximizing the providers’ ability to manage disease, minimizing providers’ use of unnecessary referrals and reducing the need for hospitalization and ER utilization. Care plans for complex case management services must include a schedule for contact with the PMP (if applicable) and other providers. In crisis situations, contact with the member, PMP (if applicable) and other providers is expected to be immediate, frequent and intense and not less than monthly. The Contractor will engage the member’s PMP (if applicable) and other significant providers in complex case management activities through ongoing, direct interaction between the provider(s) and the multidisciplinary care management team. This involvement will include semi-annual case conferences based on the member’s assessment and evaluation. The Contractor will offer to travel to the provider’s office to conduct the care conference, or conduct it via teleconference, at the provider’s option. A minimum of two (2) weeks prior to each case conference, the C...
