Initiative to Reduce Preventable Hospital Admissions. The Contractor must have and comply with written protocols to minimize unnecessary or inappropriate hospital admissions and a reporting system to record all preventable hospital admissions (see Subsection 2.14(F)(1)). The protocols must include at least the following:
a. Monitoring and risk-assessment mechanisms, which are operative on a continuous basis, to identify Enrollees at-risk of hospitalization for at least the following conditions or profiles: pneumonia, dehydration, injuries from falls, skin breakdown, loss of informal caregiver, and history of noncompliance with treatment programs;
b. Processes that link the Initial and Ongoing Assessments to the timely provision of appropriate preventive care and other treatment interventions to at-risk Enrollees. Such processes must emphasize continuity of care and coordination of services and must be in accordance with accepted clinical practice. The Contractor must perform outcome analyses to evaluate the effectiveness of the protocols; and
c. Formal linkages among the PCP, PCT, and Providers (specialty, long term care, and behavioral health) through the Centralized Enrollee Record and other mechanisms, that must be used to provide timely information to the Contractor’s Provider Network, in order to implement early interventions for Enrollees and prevent hospitalizations.
Initiative to Reduce Preventable Hospital Admissions. The Contractor must have and comply with written protocols to minimize unnecessary or inappropriate hospital admissions and a reporting system to record all preventable hospital admissions. The protocols must include at least the following:
1) Monitoring and risk-assessment mechanisms, which are operative on a continuous basis, to identify Enrollees at-risk of hospitalization for at least the following conditions or profiles: pneumonia, dehydration, injuries from falls, skin breakdown, loss of informal caregiver, and history of noncompliance with treatment programs;
2) Processes that link the Initial and Ongoing Assessments to the timely provision of appropriate preventive care and other treatment interventions to at-risk Enrollees. Such processes must emphasize continuity of care and coordination of services and must be in accordance with accepted clinical practice. The Contractor must perform outcome analyses to evaluate the effectiveness of the protocols; and
3) Formal linkages among the PCP, PCT, and Providers (specialty, long term care, and behavioral health) through the CER and other mechanisms, that must be used to provide timely information to the Contractor’s Provider Network, in order to implement early interventions for Enrollees and prevent hospitalizations.
