Disease Management Care Plans Sample Clauses

Disease Management Care Plans. Disease management care plans may be fairly basic or more involved depending on member needs. The simplest of plans would contain documentation of a member's stratification level, the condition(s) for which the member should receive disease management, the schedule of disease management interventions for those conditions, and contact information for the member's primary provider(s). Disease management care plans must include a schedule for distributing disease state related information, prevention and appointment reminders as well as an annual review.

Disease Management Care Plans. Disease management care plans may be fairly basic or more involved depending on member needs. The simplest of plans would contain documentation of a member's stratification level, the condition(s) for which the member should receive disease management, the schedule of disease management interventions for those conditions, and contact information for the member's primary provider(s). Disease management care plans must include a schedule for distributing disease state related information, prevention and appointment reminders as well as an annual review. Care management care plans will include all elements of disease management. The care plan will identify the problems, barriers and issues related to the individual’s health care needs. It will address goals, objectives and interventions to meeting the needs of the individual. 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. This will include action steps to be followed when needs are identified. This team is responsible for the initial assessment and on-going re-assessment and evaluation of care management members. Care plans should anticipate volatile healthcare needs, including a need for immediat e respite, medical advice or home health care. Care management care plans should foresee possible crisis situations where immediate additional support is needed to prevent hospitalizations, long-term care or poor outcomes. The Care Plan must describe how the Contractor will manage care for these members, including after business hours. The Contractor will engage the member’s PMP (if applicable) or other significant provider(s) in care management through ongoing, direct interaction between the provider and the multidisciplinary care management team. 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...