Common use of Disease Management Care Plans Clause in Contracts

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 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 EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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 immediate 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 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 soc ial 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. 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. The Contractor will provide complex case management through consultation services with the PMP (if applicable) and other providers to facilitate communication, engaging providers, maximizing the providers’ ability to manage disease, minimizing providers’ use of unnecessary referrals and reducing the need for hospitalization and ER utilization. Care plans for complex case management services must include a schedule for contact with the PMP (if applicable) and other providers. In crisis situations, contact with the member, PMP (if applicable) and other providers is expected to be immediate, frequent and intense and not less than monthly. The Contractor will engage the member’s PMP (if applicable) and other significant providers in complex case management activities through ongoing, direct interaction between the provider(s) and the multidisciplinary care management team. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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, EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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 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 EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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 immediate 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 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 soc ial 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. 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. The Contractor will provide complex case management through consultation services with the PMP (if applicable) and other providers to facilitate communication, engaging providers, maximizing the providers’ ability to manage disease, minimizing providers’ use of unnecessary referrals and reducing the need for hospitalization and ER utilization. Care plans for complex case management services must include a schedule for contact with the PMP (if applicable) and other providers. In crisis situations, contact with the member, PMP (if EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE applicable) and other providers is expected to be immediate, frequent and intense and not less than monthly. The Contractor will engage the member’s PMP (if applicable) and other significant providers in complex case management activities through ongoing, direct interaction between the provider(s) and the multidisciplinary care management team. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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 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 EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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 immediate 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 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 EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE due to personal issues, cognitive impairment, mental illness, lack of soc ial 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. 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. The Contractor will provide complex case management through consultation services with the PMP (if applicable) and other providers to facilitate communication, engaging providers, maximizing the providers’ ability to manage disease, minimizing providers’ use of unnecessary referrals and reducing the need for hospitalization and ER utilization. Care plans for complex case management services must include a schedule for contact with the PMP (if applicable) and other providers. In crisis situations, contact with the member, PMP (if applicable) and other providers is expected to be immediate, frequent and intense and not less than monthly. The Contractor will engage the member’s PMP (if applicable) and other significant providers in complex case management activities through ongoing, direct interaction between the provider(s) and the multidisciplinary care management team. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.

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 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 EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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 immediate 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. EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 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-self- management skills due to personal issues, cognitive impairment, mental illness, lack of soc ial 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- 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. Care plans should foresee possible crisis situations where immediate additional support is needed to prevent hospitalizations, long- long-term care or poor outcomes. The Contractor shall manage care for these members, including after business hours. The Contractor will provide complex case management through consultation services with the PMP (if applicable) and other providers to facilitate communication, engaging providers, maximizing the providers’ ability to manage disease, minimizing providers’ use of unnecessary referrals and reducing the need for hospitalization and ER utilization. Care plans for complex case management services must include a schedule for contact with the PMP (if applicable) and other providers. In crisis situations, contact with the member, PMP (if applicable) and other providers is expected to be immediate, frequent and intense and not less than monthly. The Contractor will engage the member’s PMP (if applicable) and other significant providers in complex case management activities through ongoing, direct interaction between the provider(s) and the multidisciplinary care management team. The Contractor will assertively engage members and providers in the development of a complex case management plan to help members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The member may choose to become actively engaged in learning about their health condition(s) and participating with their medical team through the member focused approach. In the alternative, a member may be unable to actively participate or may choose to remain more EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE passive, in which case, the provider focused approach would be more appropriate. Each approach for the development of complex case management care plans is detailed below.