Transitional Care Sample Clauses
The Transitional Care clause outlines the procedures and responsibilities for ensuring continuity of care when a patient moves from one healthcare setting or provider to another. Typically, this clause specifies the coordination required between outgoing and incoming care teams, including the transfer of medical records, communication of treatment plans, and arrangements for follow-up care. Its core practical function is to minimize disruptions in patient treatment, reduce the risk of medical errors, and ensure that patients receive appropriate ongoing care during periods of transition.
Transitional Care. 1. The Parties must establish policies and procedures and develop a process describing how MCP and MHP will coordinate transitional care services for Members. A “transitional care service” is defined as the transfer of a Member from one setting or level of care to another, including, but not limited to, discharges from hospitals, institutions, and other acute care facilities and skilled nursing facilities to home or community-based settings,2 or transitions from outpatient therapy to intensive outpatient therapy. For Members who are admitted to an acute psychiatric hospital, psychiatric health facility, adult residential, or crisis residential stay, including, but not limited to, Short-Term Residential Therapeutic Programs and Psychiatric Residential Treatment Facilities, where MHP is the primary payer, MHPs are primarily responsible for coordination of the Member upon 1 CalAIM Population Health Management Policy Guide available at ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/2023-PHM-Policy- Guide.pdf discharge. In collaboration with MHP, MCP is responsible for ensuring transitional care coordination as required by Population Health Management,3 including, but not limited to:
a. Tracking when Members are admitted, discharged, or transferred from facilities contracted by MHP (e.g., psychiatric inpatient hospitals, psychiatric health facilities, residential mental health facilities) in accordance with Section 11(a)(iii) of this MOU.
b. Approving prior authorizations and coordinating services where MCP is the primary payer (e.g., home services, long-term services and supports for dual-eligible Members);
c. Ensuring the completion of a discharge risk assessment and developing a discharge planning document;
d. Assessing Members for any additional care management programs or services for which they may qualify, such as ECM, CCM, or Community Supports and enrolling the Member in the program as appropriate;
e. Notifying existing CCM Care Managers of any admission if the Member is already enrolled in ECM or CCM; and
f. Assigning or contracting with a care manager to coordinate with behavioral health or county care coordinators for each eligible Member to ensure physical health follow up needs are met as outlined by the Population Health Management Policy Guide.
2. The Parties must include a process for updating and overseeing the implementation of the discharge planning documents as required for Members transitioning to or from MCP or MHP services.
3. For inpatient me...
Transitional Care. 1. The Parties must establish policies and procedures and develop a process describing how MCP and DMC-ODS will coordinate transitional care services for Members. A “transitional care service” is defined as the transfer of a Member from one setting or level of care to another, including, but not limited to, discharges from hospitals, institutions, and other acute care facilities and skilled nursing facilities to home- or community-based settings,2 level of care transitions that occur within the facility, or transitions from outpatient therapy to intensive outpatient therapy and vice versa.
2. For Members who are admitted for residential SUD treatment, including, but not limited to, Short-Term Residential Therapeutic Programs and Psychiatric Residential Treatment Facilities where DMC-ODS is the primary payer, DMC-ODS is primarily responsible for coordination of the Member upon discharge. In collaboration with DMC-ODS, MCP is responsible for ensuring transitional care coordination as required by Population Health Management,3 including, but not limited to: 2 Expectations for transitional care are defined in the PHM Policy Program Guide: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/2023-PHM-Program-Guide-a11y.pdf 3 Expectations for transitional care are defined in the PHM Policy Program Guide: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/2023-PHM-Program-Guide-a11y.pdf; see also PHM Roadmap and Strategy: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/Final-Population-Health- Management-Strategy-and-Roadmap.pdf
a. Tracking when Members are admitted, discharged, or transferred from facilities contracted by DMC-ODS in accordance with Section 11(a)(iii) of this MOU;
b. Approving prior authorizations and coordinating services where MCP is the primary payer (e.g., home services, long-term services, and supports for dual-eligible Members);
c. Ensuring the completion of a discharge risk assessment and developing a discharge planning document;
d. Assessing Members for any additional care management programs or services for which they may qualify, such as ECM, CCM, or Community Supports, and enrolling the Member in the program as appropriate;
e. Notifying existing CCM Care Managers of any admission if the Member is already enrolled in ECM or CCM; and
f. Assigning or contracting with a care manager to coordinate with county care coordinators to ensure physical health follow-up needs are met for each eligible Member as outlined by the Population Health Management Policy Guide.4
3. The...
Transitional Care. 1. The Parties must establish policies and procedures and develop a process describing how MCP and MHP will coordinate transitional care services for Members. A “transitional care service” is defined as the transfer of a Member from one setting or level of care to another, including, but not limited to, discharges from hospitals, institutions, and other acute care facilities and skilled nursing facilities to home or community-based settings,2 or transitions from outpatient therapy to intensive outpatient therapy. For Members who are admitted to an acute psychiatric hospital, psychiatric health facility, adult residential, or crisis residential stay, including, but not limited to, Short-Term Residential Therapeutic Programs and Psychiatric Residential Treatment Facilities, where MHP is the primary payer, MHPs are primarily responsible for coordination of the Member upon discharge. In collaboration with MHP, MCP is responsible for ensuring transitional care coordination as required by Population Health Management,3 including, but not limited to:
a. Tracking when Members are admitted, discharged, or transferred from facilities contracted by MHP (e.g., psychiatric inpatient hospitals, psychiatric health facilities, residential mental health facilities) in accordance with Section 11(a)(iii) of this MOU.
b. Approving prior authorizations and coordinating services where MCP is the primary payer (e.g., home services, long-term services and supports for dual-eligible Members);
c. Ensuring the completion of a discharge risk assessment and developing a discharge planning document; 2 Expectations for transitional care are defined in the PHM Policy Program Guide: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/PHM-Policy-Guide.pdf 3 Expectations for transitional care are defined in the PHM Policy Program Guide: see also PHM Roadmap and Strategy: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/Final- Population-Health-Management-Strategy-and-Roadmap.pdf
d. Assessing Members for any additional care management programs or services for which they may qualify, such as ECM, CCM, or Community Supports and enrolling the Member in the program as appropriate;
e. Notifying existing CCM Care Managers of any admission if the Member is already enrolled in ECM or CCM; and
f. Assigning or contracting with a care manager to coordinate with behavioral health or county care coordinators for each eligible Member to ensure physical health follow up needs are met as outlined by the Population Health Mana...
Transitional Care. CAS agrees to accept the Pet and provide a suitable and comfortable environment at the CAS shelter facility in its sole discretion. For the duration that the Pet is housed in a CAS shelter facility, CAS will provide the Pet with basic routine veterinary care as it deems appropriate in its sole discretion, (including but not limited to: tests, exams, vaccinations, microchipping, spay/neuter surgery, heartworm and flea protection), through CAS shelter clinics. Any Pet with a special health and/or dietary need as determined by the CAS in its sole discretion will receive a medical workup to determine the best care plan for the Pet.
Transitional Care. 1. The Parties must establish policies and procedures and develop a process describing how MCPs and DMC State Plan County will coordinate transitional care services for Members. A “transitional care service” is defined as the transfer of a Member from one setting or level of care to another, including, but not limited to, discharges from hospitals, institutions, and other acute care facilities and skilled nursing facilities to home- or community-based settings,1 level of care transitions that occur within the facility, or transitions from outpatient therapy to intensive outpatient therapy and vice versa.
2. Members who are admitted for residential SUD treatment, including Perinatal Residential Substance Use Disorder Treatment and residential SUD treatment provided to Members under the age of 21 pursuant to the EPSDT benefit mandate where DMC State Plan County is the primary payer, DMC State Plan County is primarily responsible for coordination of the Member upon discharge. In collaboration with DMC State Plan County, MCPs are responsible for ensuring transitional care coordination as required by Population Health Management,2 including, but not limited to:
a. Tracking when Members are admitted, discharged, or transferred from facilities contracted by DMC State Plan County in accordance with Section 11(a)(iii) of this MOU;
b. Approving prior authorizations and coordinating services where MCPs is the primary payer (e.g., home services, long-term services, and supports for dual-eligible Members);
c. Ensuring the completion of a discharge risk assessment and developing a discharge planning document;
d. Assessing Members for any additional care management programs or services for which they may qualify, such as ECM, CCM, or Community Supports, and enrolling the Member in the program as appropriate;
e. Notifying existing CCM Care Managers of any admission if the Member is already enrolled in ECM or CCM; and
f. Assigning or contracting with a care manager to coordinate with county care coordinators to ensure physical health follow-up needs are met for each eligible Member as outlined by the Population Health Management Policy Guide.3
3. The Parties must include in their policies and procedures a process for updating and overseeing the implementation of the discharge planning documents as required for Members transitioning to or from MCPs or DMC State Plan services;
4. For inpatient residential SUD treatment provided by DMC State Plan County or for inpatient hospi...
Transitional Care. 1. The Parties must establish policies and procedures and develop a process describing how MCP and MHP/DMC-ODS will coordinate transitional care services for Members. A “transitional care service” is defined as the transfer of a Member from one setting or level of care to another, including, but not limited to, discharges from hospitals, institutions, and other acute care facilities and skilled nursing facilities to home or community- based settings;1 for DMC-ODS, level of care transitions that occur within the facility; or transitions from outpatient therapy to intensive outpatient therapy and vice versa.
2. For MHP Members who are admitted to an acute psychiatric hospital, psychiatric health facility, adult residential, or crisis residential stay, or DMC-ODS Members who are admitted for residential SUD treatment, including, but not limited to, Short- Term Residential Therapeutic Programs and Psychiatric Residential Treatment Facilities, where MHP/DMC-ODS is the primary payer, MHP/DMC-ODS are primarily responsible for coordination of the Member upon discharge. In collaboration with MHP/DMC-ODS, MCP is responsible for ensuring transitional care coordination as required by Population Health Management,2 including, but not limited to:
a. Tracking when Members are admitted, discharged, or transferred from facilities contracted by MHP/DMC-ODS (e.g., psychiatric inpatient hospitals, psychiatric health facilities, residential mental health facilities) in accordance with Section 11(a)(iii) of this MOU;
b. Approving prior authorizations and coordinating services where MCP is the primary payer (e.g., home services, long-term services and supports for dual-eligible Members);
c. Ensuring the completion of a discharge risk assessment and developing a discharge planning document;
d. Assessing Members for any additional care management programs or services for which they may qualify, such as ECM, CCM, or Community Supports and enrolling the Member in the program as appropriate;
e. Notifying existing CCM Care Managers of any admission if the Member is already enrolled in ECM or CCM; and
f. Assigning or contracting with a care manager to coordinate with behavioral health or county care coordinators for each eligible Member to ensure physical health follow up needs are met as outlined by the Population Health 1 Expectations for transitional care are defined in the PHM Policy Program Guide: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/CalAIM/Documents/2023-PHM-Program-Guide-a11y.pdf 2 Expectati...
Transitional Care. Ownership and operation of ----------------- transitional care facilities which provide medically complex treatment to patients with long-term acute and subacute illnesses;
Transitional Care i. The Parties must establish policies and procedures and develop a process describing how MCP and MHP and DMC-ODS will coordinate transitional care services for Members. A “transitional care service” is defined as the transfer of a Member from one setting or level of care to another, including, but not limited to, discharges from hospitals, institutions, and other acute care facilities and skilled nursing facilities to home or community-based settings,3 or transitions from outpatient therapy to intensive outpatient therapy.
i. For Members who are admitted to an acute psychiatric hospital, psychiatric health facility, adult residential, crisis residential stay or residential SUD treatment, including, but not limited to, Short-Term Residential Therapeutic Programs and Psychiatric Residential Treatment Facilities, where MHP or DMC-ODS is the primary payer, MHPs and DMC-ODS are primarily responsible for coordination of the Member upon discharge. In collaboration with MHP and DMC-ODS, MCP is responsible for ensuring transitional care coordination as required by Population Health Management,4 including, but not limited to:
1. Tracking when Members are admitted, discharged, or transferred from facilities contracted by MHP (e.g., psychiatric inpatient hospitals, psychiatric health facilities, residential mental health facilities) in accordance with Section 11(a)(iii) of this MOU.
2. Approving prior authorizations and coordinating services where MCP is the primary payer (e.g., home services, long-term services and supports for dual-eligible Members);
3. Ensuring the completion of a discharge risk assessment and developing a discharge planning document;
4. Assessing Members for any additional care management programs or services for which they may qualify, such as ECM, CCM, or Community Supports and enrolling the Member in the program as appropriate;
5. Notifying existing CCM Care Managers of any admission if the Member is already enrolled in ECM or CCM; and
6. Assigning or contracting with a care manager to coordinate with behavioral health or county care coordinators for each eligible Member to ensure physical health follow up needs are met as outlined by the Population Health Management Policy Guide.
i. The Parties must include a process for updating and overseeing the implementation of the discharge planning documents as required for Members transitioning to or from MCP or MHP and DMC-ODS services.
Transitional Care. Hospital X and PACP agree to work together to identify areas where they can seek to improve the safety, quality and efficiency of care transitions between PACP and Hospital X, including, but not limited to, sharing outcome information, quality data sharing protocols to bring state-of-the-art practices to each institution. Any more specific separate agreements will be set out in additional Addendum that are consistent with the following expectations; Expectations of PACP: PACP will
1. Provide the following information quarterly to the Hospital X Continuity of Care Department for both the PACP’s SNF section and Nursing Facility section:
a. Licensed nursing and CNA Staffing Levels, including current usage of contract nursing staff
b. Notice of any founded state investigations and copies of the PCAP’s related survey findings and plans of correction
c. The PACP’s Rate of community discharges
d. The PACP’s Rate of acquired pressure ulcers
e. The PACP’s Rate of unanticipated weight loss
f. The PACP’s Rate of restraint usage
g. The PACP’s Rate of dehydration;
2. Accept new patients and readmit current patients from 10:00 a.m. until 7:00 p.m., Monday through Saturday;
3. Provide physical, occupational and speech therapy to eligible patients six days a week, if prescribed by patient’s physician;
4. Appoint one person to act as the PACP Liaison who will be the principal contact person with respect to this Agreement and who will notify the Hospital X Director, Continuity of Care, of all readmissions and opportunities for improvement in transfer processes;
5. Provide the tenure of Administrator, Director of Nursing and Medical Director at PACP;
6. Provide Medical Director’s qualifications and any certifications;
7. Provide a copy of all State Survey results and plans of correction for the preceding quarter;
8. Provide a list of services provided (see grid attached as Exhibit A);
Transitional Care. It is CMS’ intent for MOC reviews and approvals to be a multi-year process that will allow MMIPs to be granted up to a three-year approval of their MOC based on higher MOC scores above the passing standard. The specific time periods for approvals are as follows:
a. Plans that receive a score of 85% or higher were granted an approval of the CMS MOC requirement for three years.
b. Plans that receive a score in the 75% to 84% range were granted an approval of the CMS MOC requirement for two years.
c. Plans that receive a score in the 70% to 74% range were granted an approval of the CMS MOC requirement for one year. MMIPs were permitted to cure problems with their MOC submissions after their initial submission if the initial score was below 70 percent; however, any plans that resubmitted their MOCs were unable to receive more than a one-year approval by CMS.