CARE COORDINATION AND CASE MANAGEMENT. 4.11.7.1 The Contractor shall be responsible for the Care Coordination/Case Management of all Members and shall make special effort to identify Members who have the greatest need for Care Coordination, including those who have catastrophic, or other high-cost or high-risk Conditions. 4.11.7.2 The Contractor’s Care Coordination system shall emphasize prevention, continuity of care, and coordination of care. The system will advocate for, and link Members to, services as necessary across Providers and settings. Care Coordination functions include: 4.11.7.2.1 Early identification of Members who have or may have special needs; 4.11.7.2.2 Assessment of a Member’s risk factors; 4.11.7.2.3 Development of a plan of care; 4.11.7.2.4 Referrals and assistance to ensure timely access to Providers; 4.11.7.2.5 Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed; 4.11.7.2.6 Monitoring; 4.11.7.2.7 Continuity of care; and 4.11.7.2.8 Follow-up and documentation. 4.11.7.3 The Contractor shall develop and implement a Care Coordination and case management system to ensure: 4.11.7.3.1 Timely access and delivery of Health Care and services required by Members; 4.11.7.3.2 Continuity of Members’ care; and 4.11.7.3.3 Coordination and integration of Members’ care. 4.11.7.4 These policies shall include, at a minimum, the following elements: 4.11.7.4.1 The provision of an individual needs assessment and diagnostic assessment; the development of an individual treatment plan, as necessary, based on the needs assessment; the establishment of treatment objectives; the monitoring of outcomes; and a process to ensure that treatment plans are revised as necessary. These procedures must be designed to accommodate the specific cultural and linguistic needs of the Contractor’s Members; 4.11.7.4.2 A strategy to ensure that all Members and/or authorized family members or guardians are involved in treatment planning; 4.11.7.4.3 Procedures and criteria for making Referrals to specialists and subspecialists; 4.11.7.4.4 Procedures and criteria for maintaining care plans and Referral Services when the Member changes PCPs; and 4.11.7.4.5 Capacity to implement, when indicated, case management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up, monitoring of outcomes, or revision of treatment plan. 4.11.7.5 The Contractor shall submit the Care Coordination and Case Management Policies and Procedures to DCH for review and approval within ninety (90) Calendar Days of Contract Award.
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CARE COORDINATION AND CASE MANAGEMENT. 4.11.7.1 The Contractor shall be responsible for the Care Coordination/Case Management of all Members and shall make special effort to identify Members who have the greatest need for Care Coordination, including those who have catastrophic, or other high-cost or high-risk Conditions.. Revised 5/19/2008
4.11.7.2 The Contractor’s 's Care Coordination system shall emphasize prevention, continuity of care, and coordination of care. The system will advocate for, and link Members to, services as necessary across Providers and settings. Care Coordination functions include:
4.11.7.2.1 Early identification of Members who have or may have special needs;
4.11.7.2.2 Assessment of a Member’s 's risk factors;
4.11.7.2.3 Development of a plan of care;
4.11.7.2.4 Referrals and assistance to ensure timely access to Providers;
4.11.7.2.5 Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed;
4.11.7.2.6 Monitoring;
4.11.7.2.7 Continuity of care; and
4.11.7.2.8 Follow-up and documentation.
4.11.7.3 The Contractor shall develop and implement a Care Coordination and case management system to ensure:
4.11.7.3.1 Timely access and delivery of Health Care and services required by Members;
4.11.7.3.2 Continuity of Members’ ' care; and
4.11.7.3.3 Coordination and integration of Members’ ' care.
4.11.7.4 These policies shall include, at a minimum, the following elements:
4.11.7.4.1 The provision of an individual needs assessment and diagnostic assessment; the development of an individual treatment plan, as necessary, based on the needs assessment; the establishment of treatment objectives; the monitoring of outcomes; and a process to ensure that treatment plans are revised as necessary. These procedures must be designed to accommodate the specific cultural and linguistic needs of the Contractor’s 's Members;; Revised 5/19/2008
4.11.7.4.2 A strategy to ensure that all Members and/or authorized family members or guardians are involved in treatment planning;
4.11.7.4.3 Procedures and criteria for making Referrals to specialists and subspecialists;
4.11.7.4.4 Procedures and criteria for maintaining care plans and Referral Services when the Member changes PCPs; and
4.11.7.4.5 Capacity to implement, when indicated, case management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up, monitoring of outcomes, or revision of treatment plan.
4.11.7.5 The Contractor shall submit the Care Coordination and Case Management Policies and Procedures to DCH for review and approval within ninety (90) Calendar Days of Contract AwardAward and as updated thereafter.
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