Comprehensive Assessments Sample Clauses
Comprehensive Assessments a. The Contractor shall provide, at a minimum, a Comprehensive Assessment to at least the following Enrollees:
1) Enrollees with Special Health Care Needs;
2) High- or rising-risk Enrollees enrolled in enhanced care coordination as described in Section 2.4.C;
3) BH CP or LTSS CP Enrollees. For any such BH CP or LTSS CP Enrollee, the Contractor shall require its BH CPs and LTSS CPs to provide comprehensive assessments for such Enrollees;
4) Provided, however, that unless clinically appropriate, the Contractor shall not conduct a new Comprehensive Assessment if an Enrollee has had a Comprehensive Assessment within the last calendar year that includes all domains and considerations described in Section 2.3.B.4.b.
b. The Contractor shall ensure Comprehensive Assessments meet the following requirements:
1) The Comprehensive Assessment shall inform the Enrollee’s care, including but not limited to any Care Coordination activities;
2) The Comprehensive Assessment shall be a person-centered assessment of an Enrollee’s care needs and, as applicable and clinically appropriate, the Enrollee’s functional needs, accessibility needs, goals, and other characteristics;
3) The Contractor shall ensure that Enrollees requiring a Comprehensive Assessment are comprehensively assessed in a timely manner to inform the development of the member-centered Care Plan as described in this Section;
4) The Contractor shall record Comprehensive Assessments in the Enrollee’s medical record;
5) The Contractor shall ensure that the Comprehensive Assessment is completed by an individual who is not financially or otherwise conflicted, as further specified by EOHHS;
6) Comprehensive Assessments shall be appropriate to the Enrollee, shall be Enrollee-centered, and shall take place in a location that meets the Enrollee’s needs, including home-based assessments as appropriate;
7) Comprehensive Assessments shall include domains and considerations appropriate for the population receiving the Comprehensive Assessment, as further specified by EOHHS, and shall include, but may not be limited to, the following:
a) Immediate care needs and current services, including but not limited to any care coordination or management activities and any services being provided by state agencies;
b) Health conditions;
c) Medications; provided, however, for CP Enrollees, medications shall be included as further specified in Appendix G;
d) Enrollee’s ability to communicate concerns, symptoms, or care goals;
e) Functiona...
Comprehensive Assessments. Each Enrollee shall receive, and be an active participant in, a timely Comprehensive Assessment of medical, behavioral health, community- based or facility-based LTSS, and social needs completed by the Care Management team. The CICO must use Phoenix, SCDHHS’s automated Case Management system, to record the Comprehensive Assessments and to track the Long Term Care Assessments (as described in Section 2.6.4 Long Term Care Assessments). The Comprehensive Assessment will be performed using the state’s uniform assessment tools. Assessment domains will include, but not be limited to, social, functional, medical, behavioral, wellness and prevention domains, caregiver status and capabilities, as well as the Enrollee’s preferences, strengths, and goals. The CICO will complete the Comprehensive Assessment using information from the initial health screen (described in Section 2.6.2 Initial Health Screen), comprehensive data sources, and input from the Enrollee, Providers, and family/caregivers. Assessments will be completed by qualified, trained health professionals who possess a professional scope of practice, licensure, and/or credentials appropriate for responding to or managing the Enrollee’s needs. Examples of health professionals who may complete portions or all of the assessment include, but are not limited to: Registered nurses, Licensed practical nurses (under the supervision of registered nurses), Social workers, Medicaid case managers, Certified geriatric care managers, Certified community health workers The CICO will use the results of the Comprehensive Assessment to confirm the appropriate acuity or risk stratification level for the Enrollee and as the basis for developing the integrated ICP. The Enrollee will continue to receive any community-based or facility- based LTSS (i.e., respite care) in any existing waiver service plan(s) prior to the Comprehensive Assessment or reassessment. The CICO will adhere to all transition requirements for services, as outlined in Section 2.6.9.
Comprehensive Assessments.
2.6.3.1. Each Enrollee shall receive, and be an active participant in, a timely Comprehensive Assessment of medical, behavioral health, community-based or facility-based LTSS, and social needs completed by the Care Management team.
2.6.3.2. The CICO must use Phoenix, SCDHHS’s automated Case Management system, to record the Comprehensive Assessments and to track the Long Term Care Assessments (as described in Section 2.6.4 Long Term Care Assessments).
2.6.3.3. The Comprehensive Assessment will be performed using the state’s uniform assessment tools.
2.6.3.3.1. Assessment domains will include, but not be limited to, the following: social, functional, medical, behavioral, wellness and prevention domains, caregiver status and capabilities, as well as the Enrollee’s preferences, strengths, and goals.
2.6.3.4. The CICO will complete the Comprehensive Assessment using information from the initial health screen (described in Section 2.6.2 Initial Health Screen), comprehensive data sources, and input from the Enrollee, Providers, and family/caregivers.
2.6.3.5. Assessments will be completed by qualified, trained health professionals who possess a professional scope of practice, licensure, and/or credentials appropriate for responding to or managing the Enrollee’s needs. Examples of health professionals who may complete portions or all of the assessment include, but are not limited to:
2.6.3.5.1. Registered nurses,
2.6.3.5.2. Licensed practical nurses (under the supervision of registered nurses),
2.6.3.5.3. Social workers,
2.6.3.5.4. Medicaid case managers,
2.6.3.5.5. Certified geriatric care managers,
2.6.3.5.6. Certified community health workers
2.6.3.6. The CICO will use the results of the Comprehensive Assessment to confirm the appropriate acuity or risk stratification level for the Enrollee and as the basis for developing the integrated ICP.
2.6.3.7. The Enrollee will continue to receive any community-based or facility- based LTSS (i.e., respite care) in any existing waiver service plan (s) prior to the Comprehensive Assessment or reassessment. The CICO will adhere to all transition requirements for services, as outlined in Section 2.6.9.
Comprehensive Assessments. (1) Criteria for Referrals: DCYF will authorize the referral of cases to Harborview when DCYF Social Service Specialists, shared planning staffings, or Fostering Well-Being documentation determines that an eligible individual is a dependent in out-of-home care, and the DCYF FCAP Lead has approved the referral. Criteria for Referrals: Two (2) or more of the following factors must be present in the case; however, priority shall be given to those cases where three (3) or more factors are present:
(a) Multiple out-of-home placements;
(b) Chronic behavioral, emotional, physical, or educational problems;
(c) More than two years spent in out-of-home care;
(d) Assessments and evaluations have been completed, but recommendations differ as to the service plan delivery and best treatment and placement options are unknown;
(e) Child or youth is prescribed five or more psychotropic medications or any antipsychotic medications;
(f) Repetitive criminal acts or offenses by the child (including inability to comply with court order, treatment, or with conditions of probation or parole);
(g) The child has been or is returning to care subsequent to a disrupted or dissolved adoption
(h) Reunification is a primary permanency plan but cannot proceed due to:
(i) One or both parents have made minimal or no progress or;
(j) Parents have borderline capabilities with regard to caring for an exceptional needs child. An assessment will assist with determining whether the abilities match the needs or;
(k) A successful reunification is highly unlikely, due to intractable problems with the parents, but grounds for termination are not present; or
(l) Parents are partially or wholly compliant with services, but concerns remain about their capability.
(m) The family has been the subject of one or more prior dependencies.
Comprehensive Assessments. Upon notification from the Agency of availability of an open 1915 (c) waiver slot, the Contractor shall conduct a comprehensive assessment, in accordance with 42 C.F.R. § 438.208(c)(2), as described, using a tool and process prior approved by the Agency, for the waitlisted Enrolled Member. The Contractor shall refer individuals who are identified as potentially eligible for LTSS to the Agency or its designee for level of care determination, if applicable.
Comprehensive Assessments. This service is designed to establish eligibility for OhioRISE and subsequently determine the level of care coordination necessary for individuals who are determined to be eligible for OhioRISE. CANS assessments performed for potentially eligible members on an ongoing basis will be covered by the MMC or FFS programs, until the day after OhioRISE enrollment. The July 2022 MMC capitation rates include the portion of projected CANS assessment benefit expense anticipated to be covered by the MMC program during the rating period. We utilized monthly OhioRISE CANS enrollment information from ODM to project the utilization of CANS assessments covered under the MMC program. We estimated the total volume of CANS assessments by grossing up the OhioRISE enrollment projections, to account for members who failed to meet the threshold score for OhioRISE eligibility. The average unit cost was developed based on the CANS assessment rates in the OhioRISE New and Enhanced Services Fee Schedule8. Adjustment factors were developed for policy and program changes estimated to materially affect the managed care program during the July 2022 rating period that are not fully reflected in the SFY 2021 Experience Adjusted data. Program adjustments were made in the rate development process to the extent a policy or reimbursement change is deemed to have a material cost impact to the MCOs. We defined a program adjustment to be ‘material’ if the total benefit expense for any individual rate cell is impacted by more than 0.1%. In addition, program adjustments that were determined to be material in prior rate setting activities, or are material to the MyCare Ohio program, are considered material. The following is a list of program adjustments deemed immaterial based on our review of the experience data and policy change. • Medication Reviews for Children in Custody. ODM requires a consistent approach to medication reviews for children in custody. The goal is for these medication reviews is to create a meaningful way the public children services association of Ohio (PCSAs) and MCOs can collaborate to provide better care for the youth they serve, as well as provide a way to assist PCSAs in tracking antipsychotics and other prescriptions in their population. We anticipate that this change is immaterial to the MMC program. • Pharmacists as Providers. ODM implemented ORC 5164.14 effective January 15, 2021, which permits Medicaid to provide payment for health care services provided by pharmacis...
Comprehensive Assessments