Common use of Coordination of Care Clause in Contracts

Coordination of Care. The Contractor will ensure coordination of care of all covered benefits under this Agreement including those provided for children, adolescents and adults for RIte Care, Rhody Health Partners and the Affordable Care Act Adult Expansion Populations. Coordination of care includes identification and follow-up of members with significant health and social needs that are at high risk of poor health outcomes, ensuring coordination of services and appropriate referral and follow-up. In particular, the Contractor will ensure coordination between medical services and behavioral health services required by the members. The Contractor will provide a care coordination program designed to help members who may or may not have a chronic disease, but have acute physical health, behavioral health, or social needs that impact health status and/or are at risk of further exacerbation of their illness. When the members need warrants immediate attention, care coordination will ensure access to primary care and behavioral health services. The goal of care coordination is to reduce the impact of any adverse outcome. Care coordination services are short term and time limited and should not be confused with intensive care management and/or other interventions. Services may include assistance with making or keeping needed medical or behavioral health appointments, hospital discharge planning, health coaching, and referrals related to the member’s immediate needs. Members are identified for care coordination because their needs do not meet the level of intensive care management as defined in this contract. The Contractor will develop guidelines for care coordination that will be submitted to EOHHS for review and approval. The Contract will have approval from the EOHHS for any subsequent changes prior to implementation of said changes. The Contractor will demonstrate the link to other Contractor systems such as quality, member services, utilization review, and appeals and grievances. For member who are identified as having special health care needs, the Contractor will: • Approve care plans in a timely manner if the Contractor’s approval is required. • Ensure that care plans are developed in accordance with applicable state quality assurance and utilization review standards. • Ensure that care plans are reviewed upon reassessment of functional need, at least every twelve (12) months, or when the member’s circumstances or needs change significantly, or at the request of the member. As a community-based program supported by EOHHS, the Contractor is required to coordinate, participate, and collaborate with EOHHS in the enhancement and improvement of Community Health Teams. The Contractor is required to provide updates and reports on this program as requested by EOHHS.

Coordination of Care. The Contractor will ensure coordination of care of all covered benefits under this Agreement including those provided for children, adolescents and adults for RIte Care, Rhody Health Partners and the Affordable Care Act Adult Expansion Populations. Coordination of care includes identification and follow-up of members with significant health and social needs that are at high risk of poor health outcomes, ensuring coordination of services and appropriate referral and follow-up. In particular, the Contractor will ensure coordination between medical services and behavioral health services required by the members. The Contractor will provide a care coordination program designed to help members who may or may not have a chronic disease, but have acute physical health, behavioral health, or social needs that impact health status and/or are at risk of further exacerbation of their illness. When the members need warrants immediate attention, care coordination will ensure access to primary care and behavioral health services. The goal of care coordination is to reduce the impact of any adverse outcome. Care coordination services are short term and time limited and should not be confused with intensive care management and/or other interventions. Services may include assistance with making or keeping needed medical or behavioral health appointments, hospital discharge planning, health coaching, and referrals related to the member’s immediate needs. Members are identified for care coordination because their needs do not meet the level of intensive care management as defined in this contract. The Contractor will develop guidelines for care coordination that will be submitted to EOHHS for review and approval. The Contract will have approval from the EOHHS for any subsequent changes prior to implementation of said changes. The Contractor will demonstrate the link to other Contractor systems such as quality, member services, utilization review, and appeals and grievances. For member who are identified as having special health care needs, the Contractor will: •  Approve care plans in a timely manner if the Contractor’s approval is required. •  Ensure that care plans are developed in accordance with applicable state quality assurance and utilization review standards. •  Ensure that care plans are reviewed upon reassessment of functional need, at least every twelve (12) months, or when the member’s circumstances or needs change significantly, or at the request of the member. As a community-based program supported by EOHHS, the Contractor is required to coordinate, participate, and collaborate with EOHHS in the enhancement and improvement of Community Health Teams. The Contractor is required to provide updates and reports on this program as requested by EOHHS.