Common use of Complex Case Management Clause in Contracts

Complex Case Management. The CONTRACTOR shall provide a Complex Case Management Program (CCMP) for eligible members, identified by criteria listed in Section 2.8.2 of this Agreement. The goal of the program is to move members to optimal levels of health and well-being by providing timely coordination of quality services and self management support. 2.8.4.7.1 The CONTRACTOR shall offer complex case management to all members identified as eligible. Members will have the right to participate or decline participation. 2.8.4.7.2 The CONTRACTOR shall make three (3) outreach attempts as detailed in Section 2.8.4.5.2 of this agreement. 2.8.4.7.3 The CONTRACTOR shall develop and implement the Complex Case Management Program according to NCQA standard QI 7 for complex case management. 2.8.4.7.4 The CONTRACTOR shall conduct a comprehensive Health Risk Assessment to assess member’s needs to include screening for mental health and substance abuse for all members identified with a physical condition and screening for physical conditions when member’s condition is behavioral. 2.8.4.7.5 The CONTRACTOR shall provide defined ongoing member assessment for the need to move these members into a lower risk classification or into the Chronic Care Management Program. 2.8.4.7.6 The CONTRACTOR shall provide to members enrolled in the COMPLEX CASE MANAGEMENT PROGRAM the following: 1. Monthly interactive member contacts to provide individual self management support emphasizing the following: One face –to –face visit as deemed appropriate by MCO Development of a supportive member and health coach relationship Teaching disease specific management skills such as medication adherence and monitoring of the member’s condition Negotiating with members for appropriate health and behavioral changes Providing problem solving techniques Assist with the emotional impact of the member’s condition Self efficacy Providing regular and sustained monitoring and follow-up Referral and linkages 2. Providing clinical reminders around HEDIS/gaps in care 3. Providing after hours assistance with urgent or emergent member needs