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.