Requirements for Care Management Sample Clauses

Requirements for Care Management. Demonstration Plans will offer Care Management services to all Enrollees based on their risk-level to ensure effective linkages and coordination between the medical home and other providers and services and to coordinate the full range of medical and social supports, as needed, both within and outside the Demonstration Plan. All Enrollees will be assigned a Care Coordinator and a care team. As stated in section c(ii) above, Enrollees shall be assigned to one of three levels – low, moderate, or high-risk. The intensity of Care Management services will depend on an Enrollee’s risk level. For Enrollees stratified as low-risk, Demonstration Plans will provide prevention and wellness messaging and condition-specific education materials. For Enrollees stratified as moderate-risk, Demonstration Plans will provide Care Management services dedicated to problem-solving interventions. For Enrollees stratified as high-risk, Demonstration Plans will provide intensive Care Management. The State and CMS will monitor Demonstration Plans’ performance throughout the operation of the Demonstration and will require that Plans have the capacity to perform the full range of Care Management activities, health assessments, and care planning. i. Requirements for an Interdisciplinary Care Team (care team) – Every Enrollee must have access to and input in the development of an interdisciplinary care team led by a Care Coordinator. The care team will be person-centered: built on the Enrollee’s specific preferences and needs and with his or her input, delivering services with transparency, individualization, respect, linguistic and Cultural Competence, and dignity. Care teams will: 1. Be led by a Care Coordinator who is accountable for coordination of all benefits and services the Enrollee may need. Care Coordinators will have prescribed caseload limits that vary based on risk-level (see section d(iv)). Where the Care Coordinator is not also the service coordinator, the service coordinator will be incorporated into the care team; 2. Support providers in medical homes, assist in assuring integration of services and coordination of care across the spectrum of the healthcare system, and help provide Care Management for Enrollees; 3. Assure appropriate and efficient care transitions including discharge planning; 4. Assess the physical, social, and behavioral risks and needs of each Enrollee; 5. Provide medication management; 6. Provide Enrollee health education on complex clinical conditi...