Transitional Care Management. A type of Care Management program to support Members’ transition of care when discharged from an institutional clinic or inpatient setting.
Transitional Care Management the evaluation of an Enrollee’s medical care needs and coordination of any other support services in order to arrange for safe and appropriate care after discharge from one level of care to another level of care, including referral to appropriate services, as described in Section 2.3.C.2.
Transitional Care Management i. The Contractor shall develop a methodology for identifying enrollees being discharged from a care facility who are at risk of readmissions and other poor outcomes. This methodology may take into account:
1. Frequency, duration and acuity of inpatient, Skilled Nursing Facility (SNF) and LTSS admissions or ED visits;
2. Discharges and pending discharges from inpatient behavioral health services, facility-based crisis services; NICU discharges and pending discharges; and
3. Identification of patients by severity of condition, medications, risk score, healthy opportunities, and other factors the Contractor may prioritize.
ii. As part of transitional care management, the Contractor shall:
1. Outreach to the Member’s assigned PCP and other medical providers for knowledge transfer and smooth transition of care;
2. Outreach to provider to inquire about receipt of discharge plan;
3. Make best effort to obtain copy of discharge plan and if received, review with enrollee;
4. Outreach to practice regarding scheduling outpatient follow-up visit within a time frame appropriate to the specific circumstances for that enrollee;
5. Conduct medication management, including reconciliation, and support medication adherence;
6. Ensure that a care manager is assigned to manage the transition;
7. Encourage the enrollee to schedule a follow-up visit with their PCP, if discharged to home, within fourteen (14) Calendar Days of discharge;
8. Ensure that the assigned care manager follows-up with the enrollee following discharge; and
9. Develop a protocol for determining the appropriate timing and format of such outreach.
iii. The Contractor shall ensure that Comprehensive Assessment is completed and current for all Members upon completion of transitional care management, including re-assessment for Members already assigned to care management as needed.
iv. The Department shall ensure the Contractor has access to an ADT data from NCHIEA that identifies when enrollees are admitted, discharged, or transferred from one care setting to another, in real time or near real time.
v. When the Contractor receives notice of any of the following alerts, the Contractor will respond promptly, and will attempt to follow-up with the enrollee as appropriate to discuss potential outpatient services needed:
1. Same-day or next-day outreach for Contractor-designated high-risk subsets of the population with ED visit;
2. Same-day or next-day outreach for Contractor-designated high-risk subsets of the pop...
Transitional Care Management for Members that change health plans.
d) Perform Pilot-related care management responsibilities as outlined in PHP Contract Section V.C. Benefits and Management, 8. Opportunities for Health, g. Enhanced Case Management Pilots to Address Unmet Health-Related Needs, also known as Healthy Opportunities Pilot.
e) Abide by the Pilot provider complaint process described in PHP Contract Section
Transitional Care Management the evaluation of an Attributed Member’s medical care needs and coordination of any other support services in order to arrange for safe and appropriate care after discharge from one level of care to another level of care, including referral to appropriate services, as described in Section 2.5.C.2. CONTRACTOR RESPONSIBILITIES CONTRACTOR QUALIFICATIONS As further specified by EOHHS, the Contractor shall meet, and demonstrate to EOHHS that it meets, the following qualifications.
Transitional Care Management. 1. The PHP shall manage transitions of care for all Members moving from one clinical setting to another to prevent unplanned or unnecessary readmissions, emergency department visits, or adverse outcomes. 42 C.F.R. § 438.208(b)(2)(i).
2. As specified in the Department’s Transitions of Care Policy, the PHP shall manage transitions of care for identified Members transitioning between PHPs or between payment delivery systems.
3. The PHP shall develop policies and procedures for transitional care management consistent with the requirements provider here and in the Department’s Transitions of Care Policy.
4. The PHP shall develop a methodology for identifying Members in transition who are at risk of readmissions and other poor outcomes. This methodology shall take into account:
i. Frequency, duration and acuity of inpatient, SNF and LTSS admissions or ED visits;
ii. Discharges from inpatient behavioral health services, facility-based crisis services, non-hospital medical detoxification, medically supervised or alcohol drug abuse treatment center;
iii. NICU discharges; and
iv. Identification of patients by severity of condition, medications, risk score, healthy opportunities, and other factors the PHP may prioritize.
5. As part of transitional care management, the PHP shall:
i. Outreach to the Member’s AMH/PCP and all other medical providers;
ii. Facilitate clinical handoffs;
iii. Obtain a copy of the discharge plan and verify that the care manager of the Member receives and reviews the discharge plan with the Member and the facility;
iv. Ensure that a follow up outpatient and/or home visit is scheduled within a clinically appropriate time window;
v. Conduct medication management, including reconciliation, and support medication adherence;
vi. Ensure that a care manager is assigned to manage the transition;
vii. Ensure that the assigned care manager rapidly follows up with the Member following discharge; and
viii. Develop a protocol for determining the appropriate timing and format of such outreach.
6. The PHP shall ensure that Comprehensive Assessment is completed and current for all enrollees upon completion of transitional care management, including re-assessment for enrollees already assigned to care management.
7. The PHP shall have access to an ADT data source that correctly identifies when Members are admitted, discharged or transferred to/from an emergency department or hospital in real time or near real time.
8. As part of transitional care management, t...
