CARE MANAGEMENT AND COORDINATION Sample Clauses

CARE MANAGEMENT AND COORDINATION. 5.1. General Care Management and Coordination Requirements As part of the Care Management System, the CONTRACTOR shall be responsible for the management, coordination, and Continuity of Care for all its Membership and shall develop and maintain a Programmatic-Level of Policies and Procedures to address this responsibility. The CONTRACTOR shall: 5.1.1. Make a best effort to conduct an initial screen of each Enrollee’s needs, within 90 Days of the effective date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful. 5.1.2. Utilize appropriate assessment tools and Health Care Professionals in assessing a members physical and Behavioral Health care needs. 5.1.3. Develop Programmatic-Level Policies and Procedures for Care Management and Coordination of services. 5.1.4. Use Care Management and Coordination as a continuous process for: 5.1.4.1. The assessment of a Member’s physical health, Behavioral Health and social support service and assistance needs, 5.1.4.2. The identification of physical health services, Behavioral Health Services and other social support services and assistance necessary to meet identified needs, and 5.1.4.3. The assurance of timely access to and provision, coordination and monitoring of the identified services associated with physical health, Behavioral Health, and social support service and assistance to help the member maintain or improve his or her health status. 5.2. National Standards Requirements The CONTRACTOR’s Care Management Program and Care Coordination activities shall conform to the requirements and industry standards stipulated in the NCQA requirements for complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). 5.2.1. Complex Case Management Standards (NCQA) The CONTRACTOR’s shall: 5.2.1.1. Develop a detailed Program description for complex Case Management. 5.2.1.2. Have Policies and Procedures for the assessment of characteristics and needs of its Member population (including children/adolescents, individuals with disabilities and individuals with Serious and Persistent Mental Illness (SPMI), and/or Serious Emotional Disorders (SED)). 5.2.1.3. Have a Case Management System based on sound evidence. 5.2.1.4. Have a systematic process for identifying Members with complex conditions and referring them for Case Management services. 5.2.1.5. Determine the need for enhanced ser...
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CARE MANAGEMENT AND COORDINATION. 5.1. General Care Management and Coordination Requirements As part of the Care Management System, the CONTRACTOR shall be responsible for the management, coordination, and Continuity of Care for all its Membership and shall develop and maintain Policies and Procedures to address this responsibility. The CONTRACTOR shall: 5.1.1. Make a best effort to conduct an initial screen of each Enrollee’s needs, within ninety (90) Days of the effective date of Enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful. 5.1.2. Utilize appropriate assessment tools and Health Care Professionals in assessing a members physical and Behavioral Health care needs. 5.1.3. Develop Programmatic-Level Policies and Procedures for Care Management and Coordination of services. 5.1.4. Use Care Management and Coordination as a continuous process for: 5.1.4.1. The assessment of a Member’s physical health, Behavioral Health and social support service and assistance needs, 5.1.4.2. Identification of persons who need LTSS services or persons with special health care needs, 5.1.4.3. The Plan must annually provide, for Department approval, its procedures related to contacting and assessing the needs for LTSS services or other special health care needs 5.1.4.4. The identification of physical health services, Behavioral Health Services, LTSS, special needs and other social support services and assistance necessary to meet identified needs, and 5.1.4.5. The assurance of timely access to and provision, coordination and monitoring of the identified services associated with physical health, Behavioral Health, LTSS, special needs, and social support services and assistance to help the member maintain or improve his or her health status including coordinating access to services not covered by the plan. 5.2. National Standards Requirements The CONTRACTOR’s Care Management Program and Care Coordination activities shall conform to the requirements and industry standards stipulated in the NCQA requirements for complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). 5.2.1. Complex Case Management Standards (NCQA) The CONTRACTOR shall: 5.2.1.1. Develop a detailed Program description for complex Case Management. 5.2.1.2. Have Policies and Procedures for the assessment of characteristics and needs of its Member population (including children/adolescents, individ...
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CARE MANAGEMENT AND COORDINATION. 5.1. General Care Management and Coordination Requirements As part of the Care Management System, the CONTRACTOR shall be responsible for the management, coordination, and continuity of care for all its Membership and shall develop and maintain a programmatic-level of policies and procedures to address this responsibility. The CONTRACTOR shall: 5.1.1. Develop programmatic-level policies and procedures for Care Management and Coordination of services. 5.1.2. Use Care Management and Coordination as a continuous process for: The assessment of a Member’s physical health, behavioral health and social support service and assistance needs, The identification of physical health services, behavioral health services and other social support services and assistance necessary to meet identified needs, and The assurance of timely access to and provision, coordination and monitoring of the identified services associated with physical health, behavioral health, and social support service and assistance to help the member maintain or improve his or her health status. 5.2. National Standards Requirements The CONTRACTOR’s Care Management Program and Care Coordination activities shall conform to the requirements and industry standards stipulated in the NCQA requirements for Complex Case Management and by the Standards of Practice of Case Management released by the Case Management Society of America (CMSA). 5.2.1. Complex Case Management Standards (NCQA) The CONTRACTOR’s shall: Develop a detailed Program description for Complex Case Management. Have policies and procedures for the assessment of characteristics and needs of its Member population (including children/adolescents, individuals with disabilities and individuals with Serious and Persistent Mental Illness (SPMI), and/or Serious Emotional Disorders (SED)). Have a Case Management System based on sound evidence. Have a systematic process for identifying Members with complex conditions and referring them for case management services. Have automated systems to support the case management staff. Have a Case Management System that ensures appropriate documentation and follow-up. Have a Case Management System with processes for initial assessment and ongoing management of members. Measure its performance and member satisfaction. Have procedures to improve performance when necessary. 5.3. Member Risk Stratification Requirements The CONTRACTOR shall stratify its Members based on risk.
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CARE MANAGEMENT AND COORDINATION 
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Related to CARE MANAGEMENT AND COORDINATION

  • Project Management and Coordination The Engineer shall coordinate all subconsultant activity to include quality of and consistency of work and administration of the invoices and monthly progress reports. The Engineer shall coordinate with necessary local entities.

  • Care Management The Contractor’s protocol for referring members to care management shall be reviewed by OMPP and shall be based on identification through the health needs screening or when the claims history suggests need for intervention. In addition to population-based disease management educational materials and reminders, these members should receive more intensive services. Members with newly diagnosed conditions, increasing health services or emergency services utilization, evidence of pharmacy non-compliance for chronic conditions and identification of special health care needs should be strongly considered for case management. Care management services include direct consumer contacts in order to assist members with scheduling, location of specialists and specialty services, transportation needs, 24-Hour Nurse Line, general preventive (e.g. mammography) and disease specific reminders (e.g. ▇▇▇ ▇▇▇), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. The Contractor shall make every effort to contact members in care management telephonically. Materials should also be delivered through postal and electronic direct-to-consumer contacts, as well as web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level. All members with the conditions of interest shall receive materials no less than quarterly. The Contractor shall document the number of persons with conditions of interest, outbound telephone calls, telephone contacts, category of intervention, intervention delivered, mailings and website hits. Care management shall be coordinated with the Right Choices Program for members qualifying for the Right Choices Program. However, the Right Choices Program is not a replacement for care management.

  • Care Coordination Care coordination is defined as the organized delivery of member care activities between two (2) or more participants (including the member) involved in a member’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all medically necessary member care activities and is often managed by the exchange of information among participants responsible for different aspects of care.

  • Cooperation and Coordination The Parties acknowledge and agree that it is their mutual objective and intent to minimize, to the extent feasible and legal, taxes payable with respect to their collaborative efforts under this Agreement and that they shall use all commercially reasonable efforts to cooperate and coordinate with each other to achieve such objective.

  • Project Coordination The Engineer shall coordinate all subconsultant activity to include quality and consistency of deliverables and administration of the invoices and monthly progress reports. The Engineer shall coordinate with necessary local entities.