Integration and Coordination of Services. 2.5.11.1. The Contractor must promote and support advances in PCPs‘ and other providers‘ capabilities to perform as patient-centered medical homes and/or health homes that provide integrated primary care and behavioral health care. This may take the form of Behavioral Health Services being integrated into a primary care setting or vice versa. The Contractor must support capacity development in at least the Foundational Elements of Primary Care and Behavioral Health Integration described in Appendix L. With regard to the overall integration and coordination of medical, behavioral health and LTSS, beyond supporting ICTs, the Contractor may also use qualified peers and non-medical staff (e.g., Community Health Workers) to support and connect Enrollees with community-based resources.
2.5.11.2. The Contractor shall have written protocols for:
2.5.11.2.1. Generating or receiving referrals or requests for services from Enrollees and for recording and tracking the results of referrals and requests for services from Enrollees;
2.5.11.2.2. Providing or arranging for second opinions, whether in- or out-of-network at no cost to the Enrollee;
2.5.11.2.3. Sharing clinical data and ICT information, including management of medications;
2.5.11.2.4. Determining conditions and circumstances under which specialty services will be provided;
2.5.11.2.5. Tracking and coordination of Enrollee transfers from one setting to another (for example, hospital to home and nursing home to adult day health) and ensuring the provision of necessary new or Continuing Services and supports to minimize unnecessary complications related to care setting transitions;
2.5.11.2.6. Obtaining and sharing individual medical and care planning information among the Enrollee‘s caregivers, and with CMS and EOHHS for quality management and evaluation purposes; and
2.5.11.2.7. Integrating into the ICT care planning process and the ICP, as appropriate, hospice services that may be received by an Enrollee from a hospice provider.
Integration and Coordination of Services.
1. The Contractor must promote and support advances in PCPs’ and other providers’ capabilities to perform as patient-centered medical homes and/or health homes that provide integrated primary care and behavioral health care. This may take the form of Behavioral Health Services being integrated into a primary care setting or vice versa. The Contractor must support capacity development in at least the Foundational Elements of Primary Care and Behavioral Health Integration described in Appendix L. With regard to the overall integration and coordination of medical, behavioral health and LTSS, beyond supporting ICTs, the Contractor may also use qualified peers and non-medical staff (e.g., Community Health Workers) to support and connect Enrollees with community-based resources.
2. The Contractor shall have written protocols for:
a. Generating or receiving referrals and for recording and tracking the results of referrals;
b. Providing or arranging for second opinions, whether in- or out-of- network at no cost to the Enrollee;
c. Sharing clinical data and ICT information, including management of medications;
d. Determining conditions and circumstances under which specialty services will be provided;
e. Tracking and coordination of Enrollee transfers from one setting to another (for example, hospital to home and nursing home to adult day health) and ensuring the provision of necessary new or Continuing Services and supports to minimize unnecessary complications related to care setting transitions;
f. Obtaining and sharing individual medical and care planning information among the Enrollee’s caregivers, and with CMS and EOHHS for quality management and evaluation purposes; and
g. Integrating into the ICT care planning process and the ICP, as appropriate, hospice services that may be received by an Enrollee from a hospice provider.
Integration and Coordination of Services. The Contractor must ensure effective linkages of clinical and management information systems among all Providers in the Provider Network, including clinical Subcontractors (that is, acute, specialty, behavioral health, and long term care Providers). The Contractor must ensure that the PCP or the PCT integrates and coordinates services including, but not limited to:
a. An Individualized Plan of Care for each Enrollee, signed by the Enrollee or the Enrollee’s representative, developed by the PCP or, if applicable, the PCT, and the periodic review and modification of this treatment plan by the PCP or PCT;
b. Written protocols for generating or receiving referrals and for recording and tracking the results of referrals;
c. Written protocols for providing or arranging for second opinions, whether in or out of network;
d. Written protocols for sharing clinical and Individualized Plan of Care information, including management of medications;
e. Written protocols for determining conditions and circumstances under which specialty services will be provided appropriately and without undue delay to Enrollees who do not have established Complex Care Needs (for example, GSSC and specialty physician services);
f. Written protocols for tracking and coordination of Enrollee transfers from one setting to another (for example, hospital to home and nursing home to adult day health) and ensuring continued provision of necessary services; and
g. Written protocols for obtaining and sharing individual medical and care planning information among the Enrollee’s caregivers in the Provider Network, and with CMS and EOHHS for quality management and program evaluation purposes.
Integration and Coordination of Services a. The Contractor must ensure effective linkages of clinical and management information systems among all Providers in the Provider Network, including clinical Subcontractors (that is, acute, specialty, behavioral health, and long term care Providers). The Contractor must ensure that the PCP or the PCT integrates and coordinates services including, but not limited to:
1) An IPC, as described in Section 2.4.A.2 of this Contract;
2) Written protocols for generating or receiving referrals and for recording and tracking the results of referrals;
3) Written protocols for providing or arranging for second opinions, whether in or out of the Provider Network;
4) Written protocols for sharing clinical and IPC information, including management of medications;
5) Written protocols for determining conditions and circumstances under which specialty services will be provided appropriately and without undue delay to Enrollees who do not have established Complex Care Needs;
6) Written protocols for obtaining and sharing individual medical and care planning information among the Enrollee’s caregivers in the Provider Network, and with CMS and EOHHS for quality management and program evaluation purposes;
7) Coordinating the services the Contractor furnishes to the Enrollee between settings of care, including appropriate discharge planning for short- and long-term hospital and institutional stay; and
8) Coordinating services provided by the Contractor with the services:
a) The Enrollee receives from any other managed care entity;
b) The Enrollee receives in fee-for-service Medicaid; and
c) The Enrollee receives from community and social support providers.
b. The Contractor shall ensure that each Enrollee receives the contact information for the person or entity primarily responsible for coordinating the Enrollee’s care and services, whether that is the PCP or his or her designee on the PCT.
