Comprehensive Care Plan. The care coordinator must ensure that each medical home member has a comprehensive care plan. The OB care provider must be central to the development of the care plan. To the maximum extent possible, the member and the member’s PCP (if different from the OB care provider) must also be included in the development of the care plan. The care plan must address the medical and non-medical needs identified during the information gathering process and must include:
1) A listing of key health and community resources specific to the member’s needs;
2) A prioritized plan of action that reflects the member’s preferences and goals;
3) Timeframes for addressing (and following-up on) each identified need;
4) Strategies to encourage patient self-care and adherence to treatment recommendations (e.g., assisting the member in identifying self- management goals and in communicating with her obstetric care provider, offering home visits, checking in with the member between visits, referring members to group classes, and sharing culturally sensitive and appropriate materials). The care coordinator should offer home visits. Best practice suggests that the home visit occur within 30 days of enrollment in the medical home. Members, who decline the initial offer, should be asked again throughout the pregnancy. The offer attempts and refusals must be documented in the medical record. The care coordinator must establish regular communication with the member, OB care provider and PCP, if any, and any home visiting agency/provider the member may be working with, to track progress on the care plan and ensure coordinated care. The care plan must be developed by the OB care provider, the care coordinator, and the member. The provider must attest to the agreement and understanding of the care plan by the respective parties and document, including the date, within the EHR. The plan must be reviewed and updated as the member’s health and circumstances change.
Comprehensive Care Plan. Purpose The purpose of the Comprehensive Care Plan is to ensure that appropriate care is delivered to the member by following an evidence-based, member-centric treatment plan that addresses their unique needs. The Plan is developed by the care management team or the WICT and the member, incorporating the elements identified in the Screening, Information Gathering, and the Needs- stratification processes. Per 42 CFR 438.208(c)(3)(iv) of the Managed Care Rule, the Comprehensive Care Plan must be in accordance with Utilization Management requirements outlined in Article X.G. of this contract. Timeframe New and Re-enrolled Members - The Comprehensive Care Plan must be completed within 30 days of completion of the Screening or 90 days after enrollment in the HMO, whichever comes first. Current Members – All currently enrolled members must have a Comprehensive Care Plan completed by the HMO within 30 days of completion of the annual Screening. Modes of Contact The care management team or the WICT must develop the Comprehensive Care Plan in coordination with the member in- person, via interactive video (synchronous telehealth), or over the phone. Care Plan Characteristics After completing the initial Screening and the Information Gathering processes, the care management team or the WICT must develop and implement a Comprehensive Care Plan in coordination with the member that prioritizes interventions based on the member’s medical, mental, behavioral, dental health and other social needs. The Comprehensive Care Plan must have the following characteristics: Be member-centric, incorporating the member’s short and long-term health and well-being goals. Incorporate health literacy and cultural competency attributes based on the individual member needs. Reflect understanding between the member and the care management team or WICT. Identify all formal and informal supports, by name or position, that are instrumental to the member’s care plan goals (e.g. family, friends, caregivers, providers, community agencies). Include their role in executing the care plan, and if/how they will receive care plan updates. Identify the member’s current medical and non-medical needs to be addressed by the care management team or WICT including:
1) Chronic conditions and acute illnesses;
2) Mental and behavioral health conditions and history of abuse, violence, or traumatic life events;
3) Dental care needs;
4) Medications taken by the member;
5) Additional supports to conduct activities ...
Comprehensive Care Plan. 4.4.6.1 The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for developing, sharing, and updating the Comprehensive Care Plan (CCP). The process shall be consistent with the CCP requirements in this Section 4.4.6.
4.4.6.2 The CONTRACTOR shall develop and implement CCPs, using HSD’s standardized CCP, for Members in CCL2 and CCL3 within fourteen (14) Business Days of completion of the initial CNA, unless the Member is in the Treat First model of care. For Members in the Treat First model of care, the CCP shall be completed within fourteen (14) Business Days of the completion of four
