Population Health Management. We offer a variety of services to you through our Population Health Management program which includes Case Management. Case management is available to all plan members who need assistance with coordinating health care services and/or accessing resources. Registered nurses, pharmacists and social workers, referred to as Care Managers, assist members with needs spanning behavioral services and the medical community. If you are facing a serious illness or medical condition, then Case Management may be right for you. General Case Management and disease specific case management programs are available. The goals of these services are:
Population Health Management. An approach to maintain and improve physical and psychosocial well-being and address health disparities through cost-effective, person-centered health solutions that address members' health needs in multiple settings at all points along the continuum of care. Post-Stabilization Care Services – As defined in OAC rule 5160-26-01, covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 CFR
Population Health Management. All Participating practices must engage in the Clinical Practice Improvement Activities to support Population Health Management as outlined below. Participants which selected a Practice Transformation Objective other than Population Health Management in 2017 may continue to pursue that objective (e.g. telehealth adoption) but are required to realign their objective as an activity which corresponds with improving performance on one or more of their population health objectives.
Population Health Management. 2.5.2.1. The ICDS Plan is required to develop a model of care that broadly defines the way services will be delivered by the ICDS Plan, and includes requirements specified in Sections 2.5.2 and 2.5.3 of this Contract.
2.5.2.1.1. The ICDS Plan must address the following components as part of its model of care:
2.5.2.1.1.1. Descriptions of the population and specialized services: A comprehensive description of the ICDS Plan’s population and the specialized services and resources that are tailored to the population are key to the model of care. This section of the model of the care must address the following components:
Population Health Management. A. Data Aggregation and Analysis
Population Health Management. An approach to maintain and improve physical and psychosocial well- being and address health disparities through cost-effective, person-centered health solutions that address members' health needs in multiple settings at all points along the continuum of care. Post-Stabilization Care Services – As defined in OAC rule 5160-26-01, covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 CFR 422.113 to improve or resolve the member's condition. Prepaid Inpatient Health Plan (PIHP) – As defined in 42 CFR 438.2, a PIHP is an entity that 1) provides services to enrollees under contract with the State, and on the basis of capitation payments, or other payment arrangements that do not use State plan payment rates; 2) provides, arranges for, or otherwise
Population Health Management. 2.5.2.1. The ICDS Plan shall abide by the care delivery model described within this Contract and is not required to submit a model of care to CMS or ODM unless otherwise requested.
2.5.2.1.1. The ICDS Plan must include the following components in its care delivery model:
Population Health Management. In order for MCP to ensure Members have access to Medi-Cal for Kids and Teens benefits and perinatal services, MCP must coordinate with Agency as necessary. MCP must undertake such activities in accordance with the Medi-Cal Managed Care Contract, DHCS Population Health Management Program, and policy guidance,3 with a focus on high-risk populations such as Infants and Children with special needs and perinatal African Americans, Alaska Natives, and Pacific Islanders.
Population Health Management.
a. The CONTRACTOR must apply effective methods to support PARTICIPANTS’ health, reduce risks and prevent unnecessary costs. This includes, but is not limited to:
i. Managing costs for medical services, HOSPITAL confinement or other BENEFITS to be provided with evidence-based peer and utilization review mechanisms for monitoring healthcare costs.
ii. Offering complex case management programming to PARTICIPANTS.
iii. Coordinating programming with the DEPARTMENT’S wellness and chronic condition management vendor(s) by: • Integrating PARTICIPANT data provided by the DEPARTMENT’S wellness and chronic condition management vendor(s) into CONTRACTOR’S population health management system(s) and/or processes; • Using PARTICIPANT level data from the DEPARTMENT’S wellness and chronic condition management vendor(s) to identify PARTICIPANTS eligible for complex/chronic case management and enroll PARTICIPANTS in such programs; and • Refer PARTICIPANTS to the appropriate resources provided by the DEPARTMENT’S wellness and chronic condition management vendor(s) as applicable.
b. The CONTRACTOR will not give PARTICIPANTS financial or other incentives of monetary value that do not qualify as a medical expense under IRS Code Section 213(d) for participation in population health management programming.
c. The CONTRACTOR must demonstrate, upon request by the DEPARTMENT, their efforts in utilizing the PARTICIPANT level data as stated in Section III.D.3. Data Integration and Technical Requirements, in Section 4 of the Certificate of Coverage: Benefits & Coverages, and from the DEPARTMENT’S wellness and chronic condition management vendor(s) to manage population health.
d. The CONTRACTOR must provide the DEPARTMENT, upon the DEPARTMENT’S request, aggregate data on engagement and impact of the CONTRACTOR’S population health programming efforts on behalf of PARTICIPANT health, program quality and financial impact.
Population Health Management. 6.5.1 Contractor’s Care Model shall include strategies for supporting Members at various levels of risk; for example, those Members identified as low risk, medium or rising risk, high risk, and very high risk of experiencing complex health conditions. Within 90 days of the beginning of each Performance Year, Contractor shall use best practices and predictive modeling tools to conduct comprehensive screening and risk stratification to predict all Attributed Members’ risk (if possible, including tools that address needs of specific sub-populations and risk related to social determinants of health). Contractor shall provide information about screening and risk stratification tools and results to DVHA upon request.
6.5.2 Contractor shall develop strategies to support Participating Providers and care team participants in providing recommended care coordination interventions and care for Members based on level of risk. These strategies shall include:
a. Mechanisms for Participating Provider judgement, experience, or other triggering events to inform, and potentially impact, predictive risk stratification results. Contractor shall identify triggers which would immediately move Members to higher care coordination levels and shall communicate those triggers to Participating Providers.
b. Mechanisms to identify and outreach Members who are due for recommended preventive health evaluations, screenings, or chronic condition management.
c. Tools to conduct comprehensive standardized assessments, such as screenings and assessments for mental health conditions, social determinants of health, substance use disorder, suicide risk, activities of daily living, cognitive and memory function, and women of child- bearing age. DVHA reserves the right to require use of a specific screening tool(s) to ensure alignment with AHS programming.
d. Mechanisms to ensure that Participating Providers and/or care team participants work with Members to identify Members’ goals, strengths, needs and available resources to enable person-directed planning, including family and caregiver input as appropriate.
e. Regardless of level of risk, support for all Members participating in the Care Model with Member-directed goal setting; identification of strengths, barriers and challenges; selection of lead care coordinator and care team; development of a shared care plan; convening of the care team; and prioritization of goals, action steps, tasks, and milestones. Contractor shall develop processes and...
