Requirements for Care Transitions Sample Clauses

Requirements for Care Transitions. Because Demonstration Plans will be required to assure integration of primary, specialty, behavioral health, LTSS, monitor transitions between levels of care, and facilitate discharge planning, Demonstration Plans will be required to operate a SNFist program. The SNFist program must be designed to improve health outcomes among nursing home residents, particularly those with high rates of hospitalization. A SNFist program may include an adequate network of providers that are part of a coordinated group working together and specializing in medical care for the population residing in nursing homes. The SNFist program may also include visiting onsite care by the SNFist in the nursing home to provide constant monitoring of Enrollee health status and continual updates to the Enrollee Care Plan, as appropriate, or an alternative structure. Demonstration Plans may operate a hospitalist program as well to improve care transitions. Demonstration Plans that proposed a hospitalist program through their RFP response will be required to operate one under the Three-way Contract.
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Related to Requirements for Care Transitions

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