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: 4.4.10.1.1 Develop and/or update the CCP as needed; 4.4.10.1.2 Provide condition specific disease management interventions and strategies and educate Members with identified disease management needs; 4.4.10.1.3 Monitor treatment and coordinate with Providers to encourage best practice as it relates to tests, appointment frequency and adherence to condition specific protocols; 4.4.10.1.4 Educate the Member about his or her ability to have an Advance Directive and document the Member’s decision in the Member’s file; 4.4.10.1.5 Upon the scheduled initiation of services identified in the Member’s CCP, the Care Coordination team (as further addressed in Section 4.4.12) shall begin monitoring to ensure that services have been initiated and continue to be provided as authorized and that services continue to meet the Member’s needs; 4.4.10.1.6 Monitor the Member’s Community Benefit (as applicable) to ensure that the benefit sufficiently meets the Member’s needs; 4.4.10.1.7 Identify, address and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. The CONTRACTOR shall describe in policies and procedures the process for identifying, responding to and resolving service gaps in a timely manner; 4.4.10.1.8 Identify changes to the Member’s risk, address those changes and update the Member’s risk agreement as necessary; 4.4.10.1.9 Maintain appropriate ongoing communication with community and natural supports to monitor and support their ongoing participation in the Member’s care; 4.4.10.1.10 For non-Covered Services, enlist the involvement of, and coordinate with, community organizations to provide services that are important to the health, safety and well-being of Members. This may include but shall not be limited to referrals to other agencies for assistance. The CONTRACTOR shall not be responsible for the provision or quality of non-Covered Services provided by other entities; 4.4.10.1.11 For Members meeting a nursing facility level of care, conduct a level of care reassessment at least annually and within five (5) Business Days of the CONTRACTOR becoming aware that the Member’s functional or medical status has changed in a way that may affect a level of care determination. The exception to this requirement are Members who meet ongoing NF LOC criteria as stated in Section 4.1.3.1 of this Agreement; 4.4.10.1.12 If the level of care assessment indicates a change in the level of care or if the assessment was prompted by a request by a Member or a Member’s Representative for a change in level of services, the assessment shall be forwarded to the CONTRACTOR’s Utilization Management Department for review of NF LOC and/or services review, as applicable; 4.4.10.1.13 If the level of care assessment indicates no change in level of care, the CONTRACTOR shall document the date the level of care assessment was completed in the Member’s file; 4.4.10.1.14 Facilitate access to physical, Behavioral Health and/or Long-Term Care services as needed; 4.4.10.1.15 Monitor and ensure the provision of Covered Services as well as Value Added Services, if applicable and ensure that services provided meet the Member’s needs; 4.4.10.1.16 Provide assistance in resolving concerns about service delivery or Providers; 4.
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Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Ongoing Care Coordination. 4.4.10.1 The CONTRACTOR shall conduct ongoing Care Coordination care coordination to ensure that Members receive all necessary and appropriate care. Ongoing Care Coordination care coordination functions shall include at a minimum, unless the Member is enrolled in a Health Home, the following activities:
4.4.10.1.1 Develop and/or update the CCP as needed;
4.4.10.1.2 Provide condition specific disease management interventions and strategies and educate Members with identified disease management needs;
4.4.10.1.3 Monitor treatment and coordinate with Providers providers to encourage best practice as it relates to tests, appointment frequency and adherence to condition specific protocols;
4.4.10.1.4 Educate the Member about his or her ability to have an Advance Directive and document the Member’s decision in the Member’s file;file;;
4.4.10.1.5 Upon the scheduled initiation of services identified in the Member’s CCP, the Care Coordination care coordination team (as further addressed in Section 4.4.12) shall begin monitoring to ensure that services have been initiated and continue to be provided as authorized and that services continue to meet the Member’s needs;
4.4.10.1.6 Monitor the Member’s Community Benefit (as applicable) to ensure that the benefit sufficiently meets the Member’s needs;needs;;
4.4.10.1.7 Identify, address and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. The CONTRACTOR shall describe in policies and procedures the process for identifying, responding to to, and resolving service gaps in a timely manner;
4.4.10.1.8 Identify changes to the Member’s risk, address those changes and update the Member’s risk agreement as necessary;necessary;;
4.4.10.1.9 Maintain appropriate ongoing on-going communication with community and natural supports to monitor and support their ongoing participation in the Member’s care;
4.4.10.1.10 For non-Covered Services, enlist the involvement of, of and coordinate with, with community organizations to provide services that are important to the health, safety and well-being of Members. This may include but shall not be limited to referrals to other agencies for assistance. The CONTRACTOR shall not be responsible for the provision or quality of non-Covered Services provided by other entities;
4.4.10.1.11 For Members meeting a nursing facility level of care, conduct a level of care reassessment at least annually and within five (5) Business Days of the CONTRACTOR CONTRACTOR’s becoming aware that the Member’s functional or medical status has changed in a way that may affect a level of care determination. The exception to this requirement are Members who meet ongoing NF LOC criteria as stated in Section 4.1.3.1 of this Agreement;
4.4.10.1.12 If the level of care assessment indicates a change in the level of care or if the assessment was prompted by a request by a Member or a Member’s Representative for a change in level of services, the assessment shall be forwarded to the CONTRACTOR’s Utilization Management Department lead or supervising care coordinator for review of NF LOC and/or services review, as applicabledetermination;
4.4.10.1.13 If the level of care assessment indicates no change in level of care, the CONTRACTOR shall document the date the level of care assessment was completed in the Member’s file;file;;
4.4.10.1.14 Facilitate access to physical, Behavioral Health and/or Long-Term Care services as needed;
4.4.10.1.15 Monitor and ensure the provision of Covered Services as well as Value Added Services, if applicable applicable, and ensure that services provided meet the Member’s needs;
4.4.10.1.16 Provide assistance in resolving concerns about service delivery or Providersproviders;
4.4.10.1.17 Coordinate with the Member’s providers to facilitate a comprehensive, holistic, person centered approach to care;
4.4.10.1.18 As appropriate, ensure that all PASRR requirements are met prior to the Member’s admission to a Nursing Facility, including, but not limited to, 42 CFR 483.100-138;
4.4.10.1.19 Interact with both the Member and his or her providers through modern technologies (e.g., mobile applications and tools) to facilitate better care coordination and promote health behaviors;
4.4.10.1.20 Update consent forms as necessary; 4and
4.4.10.1.21 Ensure that the organization of and documentation included in the Member’s file meets all applicable CONTRACTOR standards.
4.4.10.2 The CONTRACTOR shall provide to all Contract Providers information regarding the role of the care coordinator and shall request providers and caregivers to notify a Member’s care coordinator, as expeditiously as warranted by the Member’s circumstances, of any significant changes in the Member’s condition or care, hospitalizations, or recommendations for additional services. The CONTRACTOR shall provide training to key providers and caregivers regarding the value of this communication.
4.4.10.3 The CONTRACTOR shall monitor and evaluate a Member’s emergency room and Behavioral Health crisis service utilization to determine the reason for these visits. In monitoring the Member’s emergency room and Behavioral Health crisis service use, the CONTRACTOR shall evaluate whether or not lesser acute care treatment options were available to the Member at the time and place when he/she needed such services. The care coordinator shall take appropriate action to facilitate appropriate utilization of these services, e.g., communicating with the Member’s providers, educating the Member, conducting a comprehensive needs reassessment, and/or updating the Member’s CCP to better manage the Member’s physical health or Behavioral Health condition(s).
4.4.10.4 The Member’s care coordinator shall participate as appropriate in the institutional setting’s care planning process and discharge planning processes and advocate for the Member, and shall be responsible for coordination of the Member’s physical health, Behavioral Health, and Long-Term Care needs, which shall include coordination with the institutional setting as necessary to facilitate access to physical health and/or Behavioral Health services needed by the Member and to help ensure the proper management of the Member’s acute and/or chronic physical health or Behavioral Health conditions, including Covered Services.
4.4.10.5 The CONTRACTOR shall develop policies and procedures to ensure that care coordinators are actively involved in discharge planning when a Member is hospitalized or placed in an institutional facility. The CONTRACTOR shall define circumstances that require that hospitalized Members receive an in- person visit to complete a needs reassessment and an update to the Member’s CCP as needed.
4.4.10.6 The CONTRACTOR shall ensure that at each in-person visit the care coordinator makes the following observations, responds to any observations that require intervention and documents the observations and remedies in the Member’s file:
4.4.10.6.1 Member’s physical condition including observations of the Member’s skin, weight changes, mobility and any visible injuries;
4.4.10.6.2 Member’s physical environment;;
4.4.10.6.3 Member’s satisfaction with services and care;
4.4.10.6.4 Member’s upcoming appointments;;
4.4.10.6.5 Member’s mood and emotional well-being;
4.4.10.6.6 Member’s falls and any resulting injuries;
4.4.10.6.7 A statement by the Member regarding any concerns or questions;
4.4.10.6.8 A statement from the Member’s Representative regarding any concerns or questions (when the Representative is available); and
4.4.10.6.9 Any other observations as specified by HSD.
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Ongoing Care Coordination. 4.4.10.1 The CONTRACTOR shall conduct ongoing Care Coordination care coordination to ensure that Members receive all necessary and appropriate care. Ongoing Care Coordination care coordination functions shall include at a minimum, unless the Member is enrolled in a Health Home, the following activities:
4.4.10.1.1 Develop and/or update the CCP as needed;
4.4.10.1.2 Provide condition specific disease management interventions and strategies and educate Members with identified disease management needs;
4.4.10.1.3 Monitor treatment and coordinate with Providers providers to encourage best practice as it relates to tests, appointment frequency and adherence to condition specific protocols;
4.4.10.1.4 Educate the Member about his or her ability to have an Advance Directive and document the Member’s decision in the Member’s file;
4.4.10.1.5 Upon the scheduled initiation of services identified in the Member’s CCP, the Care Coordination care coordination team (as further addressed in Section 4.4.12) shall begin monitoring to ensure that services have been initiated and continue to be provided as authorized and that services continue to meet the Member’s needs;
4.4.10.1.6 Monitor the Member’s Community Benefit (as applicable) to ensure that the benefit sufficiently meets the Member’s needs;
4.4.10.1.7 Identify, address and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. The CONTRACTOR shall describe in policies and procedures the process for identifying, responding to to, and resolving service gaps in a timely manner;
4.4.10.1.8 Identify changes to the Member’s risk, address those changes changes, and update the Member’s risk agreement as necessary;
4.4.10.1.9 Maintain appropriate ongoing on-going communication with community and natural supports to monitor and support their ongoing participation in the Member’s care;
4.4.10.1.10 For non-Covered Services, enlist the involvement of, and coordinate with, community organizations to provide services that are important to the health, safety and well-being of Members. This may include but shall not be limited to referrals to other agencies for assistance. The CONTRACTOR shall not be responsible for the provision or quality of non-Covered Services provided by other entities;
4.4.10.1.11 For Members meeting a nursing facility level of care, conduct a level of care reassessment at least annually and within five (5) Business Days of the CONTRACTOR CONTRACTOR’s becoming aware that the Member’s functional or medical status has changed in a way that may affect a level of care determination. The exception to this requirement are Members who meet ongoing NF LOC criteria as stated in Section 4.1.3.1 of this Agreement;
4.4.10.1.12 If the level of care assessment indicates a change in the level of care or if the assessment was prompted by a request by a Member or a Member’s Representative for a change in level of services, the assessment shall be forwarded to the CONTRACTOR’s Utilization Management Department lead or supervising care coordinator for review of NF LOC and/or services review, as applicabledetermination;
4.4.10.1.13 If the level of care assessment indicates no change in level of care, the CONTRACTOR shall document the date the level of care assessment was completed in the Member’s file;
4.4.10.1.14 Facilitate access to physical, Behavioral Health and/or Long-Term Care services as needed;
4.4.10.1.15 Monitor and ensure the provision of Covered Services as well as Value Added Services, if applicable applicable, and ensure that services provided meet the Member’s needs;
4.4.10.1.16 Provide assistance in resolving concerns about service delivery or providers;
4.4.10.1.17 Coordinate with the Member’s Providers to facilitate a comprehensive, holistic, person centered approach to care;
4.4.10.1.18 As appropriate, ensure that all PASRR requirements are met prior to the Member’s admission to a Nursing Facility, including, but not limited to, 42 CFR 483.100-138;
4.4.10.1.18.1 The CONTRACTOR must ensure all relevant Pre-Admission Screening and Resident Review (PASRR) documents for Members seeking admission into a Nursing Facility (NF) are included and reviewed as part of the NF LOC determination.
4.4.10.1.18.2 The PASRR level 1 assessment is conducted prior to the Member’s NF admission as per NMAC 8.312.2.18.
4.4.10.1. 18.3 If a PASRR level 1 indicates that a PASRR level 2 is needed, the NF must obtain approval for the NF admission from the Department of Health PASRR program. The PASRR level 2 assessment will identify specialized services to be provided for the Member during the NF stay.
4.4.10.1.19 Interact with both the Member and his or her providers through modern technologies (e.g., mobile applications and tools) to facilitate better care coordination and promote health behaviors;
4.4.10.1.20 Update consent forms as necessary; and
4.4.10.1.21 Ensure that the organization of and documentation included in the Member’s file meets all applicable CONTRACTOR standards.
4.4.10.1.22 The Member’s care coordinator shall inform each Member of his or her Medicaid eligibility end date and educate Members regarding the importance of maintaining eligibility which must be redetermined at least once a year.
4.4.10.1.23 Facilitate access to supports that assess housing needs and identify appropriate resources to help Members attain and maintain community housing.
4.4.10.2 The CONTRACTOR shall provide to all Contract Providers information regarding the role of the care coordinator and shall request providers and caregivers to notify a Member’s care coordinator, as expeditiously as warranted by the Member’s circumstances, of any significant changes in the Member’s condition or care, hospitalizations, or recommendations for additional services. The CONTRACTOR shall provide training to key Providers and caregivers regarding the value of this communication.
4.4.10.3 The CONTRACTOR shall monitor and evaluate a Member’s emergency room and Behavioral Health crisis service utilization to determine the reason for these visits. In monitoring the Member’s emergency room and Behavioral Health crisis service use, the CONTRACTOR shall evaluate whether or not lesser acute care treatment options were available to the Member at the time and place when he/she accessed such services. The care coordinator shall take appropriate action to facilitate appropriate utilization of these services, e.g., communicating with the Member’s Providers, educating the Member, conducting a comprehensive needs reassessment, and/or updating the Member’s CCP to better manage the Member’s physical health or Behavioral Health condition(s).
4.4.10.4 The Member’s care coordinator shall participate as appropriate in the institutional setting’s care planning process and discharge planning processes and advocate for the Member, and shall be responsible for coordination of the Member’s physical health, Behavioral Health, and Long-Term Care needs, which shall include coordination with the institutional setting as necessary to facilitate access to physical health and/or Behavioral Health services, including Covered Services, needed by the Member and to help ensure the proper management of the Member’s acute and/or chronic physical health or Behavioral Health conditions.
4.4.10.5 The CONTRACTOR shall ensure that at each in-person visit the care coordinator makes the following observations, responds to any observations that require intervention and documents the observations and remedies in the Member’s file:
4.4.10.5.1 Member's observed physical conditions such as changes in the Member's skin, weight, mobility and any visible injuries;
4.4.10.5.2 Member's physical environment such as safety concerns and cleanliness;
4.4.10.5.3 Member’s satisfaction with services and care;
4.4.10.5.4 Member’s upcoming appointments;
4.4.10.5.5 Member’s mood and emotional well-being;
4.4.10.5.6 Member’s falls and any resulting injuries;
4.4.10.5.7 A statement by the Member regarding any concerns or questions;
4.4.10.5.8 A statement from the Member’s Representative regarding any concerns or questions (when the Representative is available); 4.and
4.4.10.5.9 Any other observations as specified by HSD. 4.4.11 Member Case Files
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Ongoing Care Coordination. 4.4.10.1 The CONTRACTOR shall conduct ongoing Care Coordination care coordination to ensure that Members receive all necessary and appropriate care. Ongoing Care Coordination care coordination functions shall include at a minimum, unless the Member is enrolled in a Health Home, the following activities:
4.4.10.1.1 Develop and/or update the CCP as needed;
4.4.10.1.2 Provide condition specific disease management interventions and strategies and educate Members with identified disease management needs;
4.4.10.1.3 Monitor treatment and coordinate with Providers providers to encourage best practice as it relates to tests, appointment frequency and adherence to condition specific protocols;
4.4.10.1.4 Educate the Member about his or her ability to have an Advance Directive and document the Member’s decision in the Member’s file;
4.4.10.1.5 Upon the scheduled initiation of services identified in the Member’s CCP, the Care Coordination care coordination team (as further addressed in Section 4.4.12) shall begin monitoring to ensure that services have been initiated and continue to be provided as authorized and that services continue to meet the Member’s needs;
4.4.10.1.6 Monitor the Member’s Community Benefit (as applicable) to ensure that the benefit sufficiently meets the Member’s needs;
4.4.10.1.7 Identify, address and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. The CONTRACTOR shall describe in policies and procedures the process for identifying, responding to to, and resolving service gaps in a timely manner;
4.4.10.1.8 Identify changes to the Member’s risk, address those changes changes, and update the Member’s risk agreement as necessary;
4.4.10.1.9 Maintain appropriate ongoing on-going communication with community and natural supports to monitor and support their ongoing participation in the Member’s care;
4.4.10.1.10 For non-Covered Services, enlist the involvement of, and coordinate with, community organizations to provide services that are important to the health, safety and well-being of Members. This may include but shall not be limited to referrals to other agencies for assistance. The CONTRACTOR shall not be responsible for the provision or quality of non-Covered Services provided by other entities;
4.4.10.1.11 For Members meeting a nursing facility level of care, conduct a level of care reassessment at least annually and within five (5) Business Days of the CONTRACTOR CONTRACTOR’s becoming aware that the Member’s functional or medical status has changed in a way that may affect a level of care determination. The exception to this requirement are Members who meet ongoing NF LOC criteria as stated in Section 4.1.3.1 of this Agreement;
4.4.10.1.12 If the level of care assessment indicates a change in the level of care or if the assessment was prompted by a request by a Member or a Member’s Representative for a change in level of services, the assessment shall be forwarded to the CONTRACTOR’s Utilization Management Department lead or supervising care coordinator for review of NF LOC and/or services review, as applicabledetermination;
4.4.10.1.13 If the level of care assessment indicates no change in level of care, the CONTRACTOR shall document the date the level of care assessment was completed in the Member’s file;
4.4.10.1.14 Facilitate access to physical, Behavioral Health and/or Long-Term Care services as needed;
4.4.10.1.15 Monitor and ensure the provision of Covered Services as well as Value Added Services, if applicable applicable, and ensure that services provided meet the Member’s needs;
4.4.10.1.16 Provide assistance in resolving concerns about service delivery or providers;
4.4.10.1.17 Coordinate with the Member’s Providers to facilitate a comprehensive, holistic, person centered approach to care;
4.4.10.1.18 As appropriate, ensure that all PASRR requirements are met prior to the Member’s admission to a Nursing Facility, including, but not limited to, 42 CFR 483.100-138;
4.4.10.1.18.1 The CONTRACTOR must ensure all relevant Pre-Admission Screening and Resident Review (PASRR) documents for Members seeking admission into a Nursing Facility (NF) are included and reviewed as part of the NF LOC determination.
4.4.10.1.18.2 The PASRR level 1 assessment is conducted prior to the Member’s NF admission as per NMAC 8.312.2.18. 4.4.10.1.18.3 If a PASRR level 1 indicates that a PASRR level 2 is needed, the NF must obtain approval for the NF admission from the Department of Health PASRR program. The PASRR level 2 assessment will identify specialized services to be provided for the Member during the NF stay.
4.4.10.1.19 Interact with both the Member and his or her providers through modern technologies (e.g., mobile applications and tools) to facilitate better care coordination and promote health behaviors;
4.4.10.1.20 Update consent forms as necessary; and
4.4.10.1.21 Ensure that the organization of and documentation included in the Member’s file meets all applicable CONTRACTOR standards.
4.4.10.1.22 The Member’s care coordinator shall inform each Member of his or her Medicaid eligibility end date and educate Members regarding the importance of maintaining eligibility which must be redetermined at least once a year.
4.4.10.1.23 Facilitate access to supports that assess housing needs and identify appropriate resources to help Members attain and maintain community housing.
4.4.10.2 The CONTRACTOR shall provide to all Contract Providers information regarding the role of the care coordinator and shall request providers and caregivers to notify a Member’s care coordinator, as expeditiously as warranted by the Member’s circumstances, of any significant changes in the Member’s condition or care, hospitalizations, or recommendations for additional services. The CONTRACTOR shall provide training to key Providers and caregivers regarding the value of this communication.
4.4.10.3 The CONTRACTOR shall monitor and evaluate a Member’s emergency room and Behavioral Health crisis service utilization to determine the reason for these visits. In monitoring the Member’s emergency room and Behavioral Health crisis service use, the CONTRACTOR shall evaluate whether or not lesser acute care treatment options were available to the Member at the time and place when he/she accessed such services. The care coordinator shall take appropriate action to facilitate appropriate utilization of these services, e.g., communicating with the Member’s Providers, educating the Member, conducting a comprehensive needs reassessment, and/or updating the Member’s CCP to better manage the Member’s physical health or Behavioral Health condition(s).
4.4.10.4 The Member’s care coordinator shall participate as appropriate in the institutional setting’s care planning process and discharge planning processes and advocate for the Member, and shall be responsible for coordination of the Member’s physical health, Behavioral Health, and Long-Term Care needs, which shall include coordination with the institutional setting as necessary to facilitate access to physical health and/or Behavioral Health services, including Covered Services, needed by the Member and to help ensure the proper management of the Member’s acute and/or chronic physical health or Behavioral Health conditions.
4.4.10.5 The CONTRACTOR shall ensure that at each in-person visit the care coordinator makes the following observations, responds to any observations that require intervention and documents the observations and remedies in the Member’s file:
4.4.10.5.1 Member's observed physical conditions such as changes in the Member's skin, weight, mobility and any visible injuries;
4.4.10.5.2 Member's physical environment such as safety concerns and cleanliness;
4.4.10.5.3 Member’s satisfaction with services and care;
4.4.10.5.4 Member’s upcoming appointments;
4.4.10.5.5 Member’s mood and emotional well-being;
4.4.10.5.6 Member’s falls and any resulting injuries;
4.4.10.5.7 A statement by the Member regarding any concerns or questions;
4.4.10.5.8 A statement from the Member’s Representative regarding any concerns or questions (when the Representative is available); 4.and
4.4.10.5.9 Any other observations as specified by HSD. 4.4.11 Member Case Files
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