Ongoing Care Coordination. 4.4.10.1 The CONTRACTOR shall conduct ongoing Care Coordination to ensure that Members receive all necessary and appropriate care. Ongoing Care Coordination functions shall include at a minimum, unless the Member is enrolled in a Health Home, the following activities:
Ongoing Care Coordination. Tasks Task Details Support the client ● Whole Person Care case managers are expected to take a “whatever it takes” approach to supporting the client in reaching their goals. Coordinate with other types of providers as needed to provide holistic support. ● Use motivational interviewing. ● Help clients develop, re-establish, or maintain family or social connections ● Teach/support independent living skills ● Facilitate transition to a higher level of care as needed Provide workforce development ● Participation in the “Workforce Development Program” to create volunteer work experience opportunities ● Providing a range of employment-related support services to assist Team Members in transitioning to permanent employment, including job search classes and personalized job search support; employment development; development of internship placements and mentorship opportunities; and case management for employment-related activities. ● Working closely with case managers at partner agencies to coordinate care and ensure clients’ needs are met. ● Continuing to strengthen the Advisory Council to assist Team Members to develop marketable job skills. ● Conducting outreach to businesses to expedite hiring processes for Team Members Align visits and activities with client’s goals ● Visits and activities are shaped by the client’s goals outlined in the Care Plan and the client’s specific needs as they arise. Record all interactions ● All interactions are recorded in the Outreach Notes and tracked as tasks or events in the Care Plan sections as appropriate. ● If you need to document information in an outreach that is sensitive, put in a generic outreach note without sensitive details and refer to a plan section you can restrict for details. ● Maximum flexibility should be used in meeting clients in a physical location that works for them (may include hospital, home, etc.). Assist in enrolling patients into Medi-Cal ● For clients who are not already enrolled ● Help with renewal as needed Document important events by using templates in Alerts and Updates ● Emergency Department visits ● Hospitalizations ● Housing status changes (homeless to housed or housed to homeless) ● Incarcerations ● Jail Release Non-statutory milestones subject to shift based on quarterly reports to state; HHS will work with contractor to determine necessary changes. Exhibit B: Scope of Work Community Action Marin Encampment Resolution Funds-2: Xxxxxxxx Xxxxx July 1, 2023 – June 30, 2025 Total Contract A...
Ongoing Care Coordination
