Common use of Complex Case Management Care Plans Clause in Contracts

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 significant providers in complex case management activities through ongoing, direct interaction between the provider(s) and the multidisciplinary care management team. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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-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-long- term care or poor outcomes. The Contractor shall 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 Contractor will solicit input from the member’s PMP for updating the care plan, consideration for appropriate stratification and participation in the conference. Contractors shall reimburse providers for their time at these care conferences as described further in Section 3.5. The Contractor must evaluate all members determined to need complex case management services during a home visit where the Contractor can assess the member’s environment and available resources. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-cost effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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-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-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-long- term care or poor outcomes. The Contractor shall 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 Contractor will solicit input from the member’s PMP for updating the care plan, consideration for appropriate stratification and participation in the conference. Contractors shall reimburse providers for their time at these care conferences as described further in Section 3.5. The Contractor must evaluate all members determined to need complex case management services during a home visit where the Contractor can assess the member’s environment and available resources. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-cost effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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-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-long- term care or poor outcomes. The Contractor shall 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 Contractor will solicit input from the member’s PMP for updating the care plan, consideration for appropriate stratification and participation in the conference. Contractors shall reimburse providers for their time at these care conferences as described further in Section 3.5. The Contractor must evaluate all members determined to need complex case management services during a home visit where the Contractor can assess the member’s environment and available resources. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-cost effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

Complex Case Management Care Plans. Complex case management services are defined by multiple medical needsneeds , high risk issues such as significant deterioration in health status or ongoing lack of self-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, EXHIBIT 1.A. SCOPE OF WORK 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 conditionsconditions , 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-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 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 Contractor will solicit input from the member’s PMP for updating the care plan, consideration for appropriate stratification and participation in the conference. Contractors shall reimburse providers for their time at these care conferences as described further in Section 3.5. The Contractor must evaluate all members determined to need complex case management services during a home visit where the Contractor can assess the member’s environment and available resources. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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-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-long- term care or poor outcomes. The Contractor shall 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 EXHIBIT 1.M SCOPE OF WORK 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 Contractor will solicit input from the member’s PMP for updating the care plan, consideration for appropriate stratification and participation in the conference. Contractors shall reimburse providers for their time at these care conferences as described further in Section 3.5. The Contractor must evaluate all members determined to need complex case management services during a home visit where the Contractor can assess the member’s environment and available resources. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-cost effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.