Section Care Management for Serious Mental Illness (SMI) Members

Size: px
Start display at page:

Download "Section Care Management for Serious Mental Illness (SMI) Members"

Transcription

1 Section Care Management for Serious Mental Illness (SMI) Members Introduction Scope Objectives Procedures A. Responsibilities B. Eligibility C. Member Identification for Care Management D. Case Analysis Review (CAR) E. Condition Specific Review Tool F. Care Planning G. Case Updates H. Case Rounds I. Criteria for Discharge from the Care Management Program J. Program Oversight and Responsibilities Introduction The care management program has been designed to improve member healthcare outcomes by providing needed care in the most appropriate setting in a culturally competent and accessible format. The care management program s primary goals are: Identify the top tier of high risk/high cost members with serious mental illness who would benefit from a fully integrated health care program; Effectively transition members from one level of care to another; Streamline, monitor and adjust members care plans based on progress and outcomes; Reduce hospital admissions and unnecessary emergency department and crisis service use; and Provide members with the proper tools to self-manage care in order to safely live work and integrate into the community Scope This section applies to all providers rendering services to the SMI members Objectives This section describes the responsibilities, eligibility, and requirements of care management Procedures A. Responsibilities Mercy Maricopa s Chief Medical Officer (CMO) is responsible for directing and overseeing Mercy Maricopa s care management program with the assistance of the Medical Management Administrator and the Director of Care Management. This oversight includes ensuring the Page

2 incorporation of treatment practice guidelines into the care management practice and program B. Eligibility Mercy Maricopa s care management program is available to enrolled members who qualify for the care management program, are Title XIX, categorized as having a serious mental illness, and who qualify for the care management program. The assessed needs of the member determine the level and type of care management. Typical members are those who: Are at high risk of poor health outcomes and high utilization; Have an acute or chronic diagnosis or condition; Have inappropriately managed their health care, and require more complex or frequent healthcare and services C. Member Identification for Care Management Mercy Maricopa utilizes data from multiple sources to identity members who may benefit from care management to meet their individualized needs. These tools allow for members to be stratified into a case registry and their specific risks identified, including chronic co-morbid conditions and specific gaps in care. Members may be identified through population-based tools (i.e., predictive modeling) and individual-based tools (i.e., Health Risk Assessment [HRA]). These tools include the following: CORE Report (predictive modeling) Health Risk Assessment On a monthly basis, HRAs are incorporated into predictive modeling reports to further identify members that may need care management. These reports also assist in identifying the appropriate care management level, particularly for those members with the greatest potential for improved health outcomes and increased cost-effective treatment. In addition, members are identified for care management through various referral sources from within Mercy Maricopa and through external sources. These referral sources include, but are not limited to, the following: Member self-referral Family and/or caregiver Interdisciplinary Team (IDT) Utilization Management (UM) referral Quality Management (QM) referral Various other Mercy Maricopa departments Discharge planner referral Provider referral Provider submissions of the American College of Obstetricians and Gynecologists [ACOG] comprehensive assessment tool Page

3 Provider submission of an Early Periodic Screening, Diagnosis, and Treatment (EPSDT) tracking form Division of Behavioral Health Services (DBHS) AHCCCS Department of Economic Security (DES)/Division of Developmental Disabilities To make a referral to the Care Management program, contact , Option 2 for Provider Calls then Option 6 for a Behavioral Health Representative. Upon receipt of referral, Mercy Maricopa s Care Management department will assess the member s eligibility against the aforementioned criteria and provide written notification of placement decision within 30 days of referral D. Case Analysis Review (CAR) If eligible, the assigned care manager completes an initial member CAR within thirty (30) calendar days of the determination of eligibility for care management and quarterly thereafter until the member is discharged from the care management program. The CAR includes the following items at a minimum: A medical chart review to identify member current health status, current providers service utilization, specific gaps in care Consultation with the member s treatment team Review of administrative data, including claims and encounter data Demographic and customer service data Root cause analysis as to over/under utilization Medication review, including updating a member medication list Placement review, including updating a member placement history Based on the CAR, the member s stratification level may be modified to best meet their needs E. Condition Specific Review Tool Upon completion of the CAR, specific disease conditions may be noted. If the member has any chronic conditions such as, asthma, diabetes, or Hypertension, the care manager is to complete the corresponding condition specific assessment F. Care Planning The information gleaned from the CAR is used in the development of a member centric plan of care that is streamlined and supports the member s physical and behavioral health, social and community service needs, placement goals and preferences. All members enrolled in the care management program shall have a care plan. The care manager and members of the treatment team each participate in the development of the care plan which is designed to prioritize goals that consider the member s and caregiver s strengths, needs, goals, and preferences. Page

4 The care management plan at a minimum shall include the following elements: Member demographics Identification of the member s treatment team Member conditions Member s/family s vision Identified protective factors Identified barriers Interventions recommended to the treatment care team, including responsible party and target date for completion Coordination gaps and strategies to improve care coordination, including an identified responsible party(ies) Strategies to monitor referrals and follow-up for specialty care and routine health care services, including medication monitoring. Each follow up item includes an identified responsible party(ies) The care plan shall align with the member s Individual Recovery Plan/Individual Service Plan, but shall be neither a part of nor a substitute for that plan. As part of the care planning process, the care manager documents a schedule for follow up with the treatment team and convenes care plan reviews at intervals consistent with the identified member care needs and to ensure progress and safety. Care plan reviews are pre-scheduled and designed to evaluate progress toward care plan goals and meeting member needs. The care plan can be revised/adjusted at any point based on member progress and outcomes. The care plan identifies the next point of review and is saved in the member s electronic record in the care management business application system G. Case Updates Coordination of care and service needs occurs regularly to ensure efficient utilization and to avoid any gaps or duplications in services. When care plans are reviewed, the need for care plan updates, a change in level of care management, and ongoing care management needs are evaluated. Care plans are verbally shared and are also mailed to the care team and/or made available via Mercy Maricopa s secure portal. To encourage involvement by the treatment team, the care manager facilitates communication across various disciplines and care settings within and outside Mercy Maricopa, including the SMI clinic, primary care practitioner (PCP) or health home and any other health or service providers who work with the member to deliver services and ensure comprehensive care. This may be done through site visits, phone calls, written communication, or in-person interdisciplinary care team conferences. Page

5 The treatment team supports the care planning process by providing an array of expertise that helps the team coordinate and integrate fragmented services to best address each member s individual needs within the context of their family, circle of supports, and cultural community. Together they: Coordinate care across the spectrum of the health care system including managing transitions between levels of care. Assist in early identification of changes in health status of members. Provide self management training and health education to members and circle of supports regarding conditions and psychosocial behaviors. View the member s situation as a whole, including all supports, caregivers, family members, and significant others, as well as the environment in which they live. Assure that behavioral health, social and functional needs are met. Identify and coordinate the provision of community resources and non covered services. Utilize evidence-based practices that can connect at-risk individuals to care via the use of well-defined action steps that are designed to produce healthy outcomes. Aim to provide member-centered care management H. Case Rounds A member s unique care needs can also be addressed through formal interdisciplinary case rounds. In case rounds, both treatment and non-treatment staff may present cases to their peers and treatment leaders to seek guidance and recommendations on how to best address the member s physical, behavioral and social care needs. Case rounds typically focus on members who are at high risk, have complex co-morbid conditions and/or have difficulty sustaining an effective working relationship with treatment and/or non-treatment staff. Case rounds may also include representatives from the member s treatment team. Case rounds are done bi-weekly, twice a month I. Criteria for Discharge from the Care Management Program Discharge from care management is considered whenever: Care plan goals have been met including stabilization of the member s condition, successful links to community support and education, and improved member health. The member has received maximum benefit from care management. Member is no longer enrolled in the Title XIX SMI program and needs to be transitioned to new programs. Member death J. Program Oversight and Responsibilities Mercy Maricopa s CMO is primarily responsible for directing and overseeing the care management activities and processes with the intention of supporting continuous process improvement. The Utilization Management Committee supports the Care Management Department and the CMO s activities to continuously monitor the performance of the care Page

6 management team and the care and services they provide to members. A population assessment is conducted annually to assess the characteristics and needs of the member population and relevant subpopulations, and includes, but is not limited to, number of members, gender, age and top ten (10) diagnoses. The population assessment is evaluated against the care management program, procedures and resources and is updated if necessary, to address member needs. The information is included in the yearly Care Management Evaluation. Outcome reports are done monthly. Page

Passport Advantage Provider Manual Section 10.0 Care Management Table of Contents

Passport Advantage Provider Manual Section 10.0 Care Management Table of Contents Passport Advantage Provider Manual Section 10.0 Care Management Table of Contents 10.1 Model of Care 10.2 Medication Therapy Management 10.3 Care Coordination 10.4 Complex Case Management 10.0 Care Management

More information

V. Utilization Management (UM) Program

V. Utilization Management (UM) Program V. Utilization Management (UM) Program Overview Better Health Network s Utilization Management (UM) Program is designed to provide quality, cost-effective and medically necessary services while meeting

More information

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.9 Case Management Services G.12 Special Needs Services

More information

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions...

CHAPTER 535 HEALTH HOMES. Background... 2. Policy... 2. 535.1 Member Eligibility and Enrollment... 2. 535.2 Health Home Required Functions... TABLE OF CONTENTS SECTION PAGE NUMBER Background... 2 Policy... 2 535.1 Member Eligibility and Enrollment... 2 535.2 Health Home Required Functions... 3 535.3 Health Home Coordination Role... 4 535.4 Health

More information

HealthCare Partners of Nevada. Heart Failure

HealthCare Partners of Nevada. Heart Failure HealthCare Partners of Nevada Heart Failure Disease Management Program 2010 HF DISEASE MANAGEMENT PROGRAM The HealthCare Partners of Nevada (HCPNV) offers a Disease Management program for members with

More information

Standards of Practice & Scope of Services. for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals

Standards of Practice & Scope of Services. for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals A M E R I C A N C A S E M A N A G E M E N T A S S O C I A T I O N Standards of Practice & Scope of Services for Health Care Delivery System Case Management and Transitions of Care (TOC) Professionals O

More information

2012 Indiana Health Coverage Programs Annual Seminar. Care Select 101: Indiana Care Select Program Overview

2012 Indiana Health Coverage Programs Annual Seminar. Care Select 101: Indiana Care Select Program Overview PCS0144 (9/12) Mitchell E. Daniels, Jr., Governor State of Indiana Indiana Family and Social Services Administration 2012 Indiana Health Coverage Programs Annual Seminar Care Select 101: Indiana Care Select

More information

MedStar Family Choice (MFC) Case Management Program. Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015

MedStar Family Choice (MFC) Case Management Program. Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015 MedStar Family Choice (MFC) Case Management Program Cyd Campbell, MD, FAAP Medical Director, MFC MCAC June 24, 2015 Case Management Program Presentation Overview CM Programs Disease Management Complex

More information

Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations (DRAFT AS OF 6/12/2015)

Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations (DRAFT AS OF 6/12/2015) Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations (DRAFT AS OF 6/12/2015) Introduction: The purpose of this guidance document is to explain

More information

2014 Model of Care Training SHP_2014838A

2014 Model of Care Training SHP_2014838A 2014 Model of Care Training SHP_2014838A 1 Model of Care Training This course is offered to meet the CMS regulatory requirements for Model of Care Training for our Special Needs Plans. It also ensures

More information

High Desert Medical Group Connections for Life Program Description

High Desert Medical Group Connections for Life Program Description High Desert Medical Group Connections for Life Program Description POLICY: High Desert Medical Group ("HDMG") promotes patient health and wellbeing by actively coordinating services for members with multiple

More information

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs Idaho Health Home State Plan Amendment Matrix: Summary Overview This matrix outlines key program design features from health home State Plan Amendments (SPAs) approved by the Centers for Medicare & Medicaid

More information

How To Manage Health Care Needs

How To Manage Health Care Needs HEALTH MANAGEMENT CUP recognizes the importance of promoting effective health management and preventive care for conditions that are relevant to our populations, thereby improving health care outcomes.

More information

Member name, address, phone number, DOB, MC400 Member ID, MA Recipient Number

Member name, address, phone number, DOB, MC400 Member ID, MA Recipient Number CONNECTED CARE DATA TEMPLATE Member Tier Display SMI Tier 1, 2, or 3 (plus historical activity to show changes in tier) Member Demographics Member name, address, phone number, DOB, MC400 Member ID, MA

More information

2013 Complex Case Management Program Description. Our mission is to improve the health and quality of life of our members

2013 Complex Case Management Program Description. Our mission is to improve the health and quality of life of our members 2013 Complex Case Management Program Description Our mission is to improve the health and quality of life of our members I. Purpose To improve the health status and quality of life of members with multiple

More information

MODULE 11: Developing Care Management Support

MODULE 11: Developing Care Management Support MODULE 11: Developing Care Management Support In this module, we will describe the essential role local care managers play in health care delivery improvement programs and review some of the tools and

More information

Attachment A Minnesota DHS Community Service/Community Services Development

Attachment A Minnesota DHS Community Service/Community Services Development Attachment A Minnesota DHS Community Service/Community Services Development Applicant Organization: First Plan of Minnesota Project Title: Implementing a Functional Daily Living Skills Assessment to Predict

More information

caresy caresync Chronic Care Management

caresy caresync Chronic Care Management caresy Chronic Care Management THE PROBLEM Chronic diseases and conditions, including heart disease, diabetes, COPD and obesity, are among the most common, expensive, and preventable health problems in

More information

Population Health Solutions for Employers MEDIA RESOURCES

Population Health Solutions for Employers MEDIA RESOURCES Population Health Solutions for Employers MEDIA RESOURCES ABOUT MISSIONPOINT MissionPoint s mission is to make healthcare more affordable, accessible and improve the quality of care for our members. MissionPoint

More information

Iowa Medicaid Integrated Health Home Provider Agreement General Terms

Iowa Medicaid Integrated Health Home Provider Agreement General Terms Iowa Medicaid Integrated Health Home Provider Agreement General Terms This Agreement is between the state of Iowa, Department of Human Services, (the Department ) and the Provider (the Provider ). The

More information

Service Inventory of Managed Care Entities to Support Development of a Health Homes State Plan Amendment

Service Inventory of Managed Care Entities to Support Development of a Health Homes State Plan Amendment Service Inventory of Managed Care Entities to Support Development of a Health Homes State Plan Amendment March 2012 MassHealth Managed Care Entities (MCO, SCO, PACE) Health Homes Inventory to Support State

More information

Guide to Chronic Disease Management and Prevention

Guide to Chronic Disease Management and Prevention Family Health Teams Advancing Primary Health Care Guide to Chronic Disease Management and Prevention September 27, 2005 Table of Contents 3 Introduction 3 Purpose 4 What is Chronic Disease Management

More information

Implementing Chronic Care Management (CCM) - CPT 99490

Implementing Chronic Care Management (CCM) - CPT 99490 Implementing Chronic Care Management (CCM) - CPT 99490 Dulcian, Inc. May 2015 The Need Population-based statistics published by the Centers for Medicare and Medicaid Services (CMS) tell the story. Most

More information

Kaiser Permanente of Ohio

Kaiser Permanente of Ohio Kaiser Permanente of Ohio Chronic Disease Management Program March 11, 2011 Presenters: Amy Kramer and Audrey L. Callahan 1 Objectives 1. Define the roles and responsibilities of the Care Managers in the

More information

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management

Medical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management Page1 G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify G.6 When to Notify G.11 Case Management Services G.14 Special Needs Services G.16 Health Management Programs

More information

Making the Grade! A Closer Look at Health Plan Performance

Making the Grade! A Closer Look at Health Plan Performance Primary Care Update August 2011 Making the Grade! A Closer Look at Health Plan Performance HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized measures designed to track

More information

Section IX Special Needs & Case Management

Section IX Special Needs & Case Management SPECIAL NEEDS & CASE MANAGEMENT Section IX Special Needs & Case Management Special Needs and Case Management 180 Integrated Care Management/Complex Case Management The Case Management/Care Coordination

More information

IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis

IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis IRG/APS Healthcare Utilization Management Guidelines for West Virginia Health Homes - Bipolar and Hepatitis CHANGE LOG Medicaid Chapter Policy # Effective Date Chapter 535 Health Homes 535.1 Bipolar and

More information

Aetna Better Health Aetna Better Health Kids. Quality Management Utilization Management. 2013 Program Evaluation

Aetna Better Health Aetna Better Health Kids. Quality Management Utilization Management. 2013 Program Evaluation Aetna Better Health Aetna Better Health Kids Quality Management Utilization Management 2013 Program Evaluation EXECUTIVE SUMMARY Introduction Aetna Better Health implemented its Medicaid Physical Health-Managed

More information

Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations. As of October 5, 2015

Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations. As of October 5, 2015 Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations As of October 5, 2015 Introduction: The purpose of this guidance document is to explain

More information

BEACON HEALTH STRATEGIES, LLC TELEHEALTH PROGRAM SPECIFICATION

BEACON HEALTH STRATEGIES, LLC TELEHEALTH PROGRAM SPECIFICATION BEACON HEALTH STRATEGIES, LLC TELEHEALTH PROGRAM SPECIFICATION Providers contracted for the telehealth service will be expected to comply with all requirements of the performance specifications. Additionally,

More information

Population Health Management & the Medical Neighborhood. Patient Centered Primary Care Collaborative Monthly National Briefing September 26, 2013

Population Health Management & the Medical Neighborhood. Patient Centered Primary Care Collaborative Monthly National Briefing September 26, 2013 Population Health Management & the Medical Neighborhood Patient Centered Primary Care Collaborative Monthly National Briefing September 26, 2013 Outline What is Population Health Management? Registries

More information

Breathe With Ease. Asthma Disease Management Program

Breathe With Ease. Asthma Disease Management Program Breathe With Ease Asthma Disease Management Program MOLINA Breathe With Ease Pediatric and Adult Asthma Disease Management Program Background According to the National Asthma Education and Prevention Program

More information

UCare provides case management for all UCare members not affiliated with one of the above listed care systems. 2011 UCare for Seniors

UCare provides case management for all UCare members not affiliated with one of the above listed care systems. 2011 UCare for Seniors Case Requirements Updated 3/16/2011 According to the Case Society of America (CMSA), Case Model Act of 2009, Case management is a collaborative process of assessment, planning, facilitation, care coordination,

More information

Integrated Healthcare Management (IHM) Overview

Integrated Healthcare Management (IHM) Overview Integrated Healthcare Management (IHM) Overview MCO Case Management Presentations MCAC on June 24, 2015 Karen Dale, Market President Pillars of Our Strategy Care Management Care Coordination Care Customization

More information

Provider Manual. Section 18.0 - Case Management and Disease Management

Provider Manual. Section 18.0 - Case Management and Disease Management Section 18.0 - Case Management and Disease Management 18.1.1 Introduction 18.2.1 Scope 18.3.1 Objectives 18.4.1 Procedures Case Management 18.4.1-A. Referrals 18.4.1-B. Case Management Mercy Maricopa Acute

More information

Provider Delivered Care Management Payment Policy and Billing Guidelines for Medicare Advantage

Provider Delivered Care Management Payment Policy and Billing Guidelines for Medicare Advantage Provider Delivered Care Management Payment Policy and Billing Guidelines for Medicare Advantage Purpose Beginning April 1, 2012, BCBSM began accepting and paying claims for Provider Delivered Care Management

More information

Disease Management Identifications and Stratification Health Risk Assessment Level 1: Level 2: Level 3: Stratification

Disease Management Identifications and Stratification Health Risk Assessment Level 1: Level 2: Level 3: Stratification Disease Management UnitedHealthcare Disease Management (DM) programs are part of our innovative Care Management Program. Our Disease Management (DM) program is guided by the principles of the UnitedHealthcare

More information

Section IX Special Needs & Case Management

Section IX Special Needs & Case Management Section IX Special Needs & Case Management Special Needs and Case Management 179 Integrated Care Management/Complex Case Management The Case Management/Care Coordination (CM/CC) program is a population-based

More information

SECTION VII: Behavioral Health Services

SECTION VII: Behavioral Health Services OVERVIEW Behavioral Health Services (mental health and/or substance abuse services) are covered for all members except those enrolled in family planning services only. Care1st manages the delivery of select

More information

Medicare: 2015 Model of Care Training 04/2015

Medicare: 2015 Model of Care Training 04/2015 Medicare: 2015 Model of Care Training 04/2015 1 Model of Care Training This course is offered to meet the CMS regulatory requirements for Model of Care Training for our Special Needs Plans. It also ensures

More information

CCNC Care Management

CCNC Care Management CCNC Care Management Community Care of North Carolina (CCNC) is a statewide population management and care coordination infrastructure founded on the primary care medical home model. CCNC incorporates

More information

Healthy Living with Diabetes. Diabetes Disease Management Program

Healthy Living with Diabetes. Diabetes Disease Management Program Healthy Living with Diabetes Diabetes Disease Management Program Healthy Living With Diabetes Diabetes Disease Management Program Background According to recent reports the incidence of diabetes (type

More information

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs)

Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Oregon Standards for Certified Community Behavioral Health Clinics (CCBHCs) Senate Bill 832 directed the Oregon Health Authority (OHA) to develop standards for achieving integration of behavioral health

More information

ADDENDUM 1 MEDICAL HOME TO SOONERCARE PHYSICIAN AGREEMENT FOR CHOICE PRIMARY CARE PROVIDERS

ADDENDUM 1 MEDICAL HOME TO SOONERCARE PHYSICIAN AGREEMENT FOR CHOICE PRIMARY CARE PROVIDERS ADDENDUM 1 MEDICAL HOME TO SOONERCARE PHYSICIAN AGREEMENT FOR CHOICE PRIMARY CARE PROVIDERS 1.0 PURPOSE The purpose of this Addendum is for OHCA and PROVIDER to contract for PCP services in OHCA s SoonerCare

More information

Building an Accountable Care Organization. Jean Malouin, MD MPH University of Michigan Health System September 21, 2012

Building an Accountable Care Organization. Jean Malouin, MD MPH University of Michigan Health System September 21, 2012 Building an Accountable Care Organization Jean Malouin, MD MPH University of Michigan Health System September 21, 2012 Agenda UMHS overview PGP demo ACO precursor Current efforts underway Role of primary

More information

MERCY MARICOPA INTEGRATED CARE Job list*

MERCY MARICOPA INTEGRATED CARE Job list* MERCY MARICOPA INTEGRATED CARE Job list* Position Integrated Health Care Development Officer Chief Clinical Officer Arizona-licensed clinical practitioner Children's Medical Arizona-licensed physician,

More information

NCQA PCMH 2011 Standards, Elements and Factors Documentation Guideline/Data Sources

NCQA PCMH 2011 Standards, Elements and Factors Documentation Guideline/Data Sources NCQA PCMH 2011 Standards, Elements and Factors Documentation Guideline/Data Sources Key: DP = Documented Process N/D = Report numerator and denominator creating percent of use RPT = Report of data or information

More information

MDFlow Case Management & Disease Management (CM/DM) System

MDFlow Case Management & Disease Management (CM/DM) System MDFlow Case Management & Disease Management (CM/DM) System The COMPLETE and CUSTOMIZED Case and Disease Management Solution for Healthcare Payers (HMOs, PPOs and MA Plans) Accountable Care Organizations

More information

Policy and Procedure Manual

Policy and Procedure Manual Policy and Procedure Manual Resident Assessment (RA) Table of Contents RA-01 RA-02 RA-03 RA-04 RA-05 RA-06 RA-07 RA-08 RA-09 RA-10 RA-11 RA-12 RA-13 Admission. History, Physicals and Routine Health Care

More information

Practice and Transformation Taskforce: CCIP. Design Group 3, Session 2: Technology Enablers & Monitoring Performance August 20 th, 2015

Practice and Transformation Taskforce: CCIP. Design Group 3, Session 2: Technology Enablers & Monitoring Performance August 20 th, 2015 Practice and Transformation Taskforce: CCIP Design Group 3, Session 2: Technology Enablers & Monitoring Performance August 20 th, 2015 1 Meeting Agenda Item 1. Meeting Objectives Allotted Time 5 min 2.

More information

Clinic/Provider Name (Please Print or Type) North Dakota Medicaid ID Number

Clinic/Provider Name (Please Print or Type) North Dakota Medicaid ID Number Contract to Provide Health Management Services Supplementary Agreement Between The Department of Human Services, Medical Services Division (North Dakota Medicaid) and Clinic/Provider Name (Please Print

More information

Section 6. Medical Management Program

Section 6. Medical Management Program Section 6. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.

More information

Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: February 19, 2014

Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: February 19, 2014 Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: February 19, 2014 Introduction The Office of Mental Health (OMH) licensed and regulated Assertive Community

More information

2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF)

2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) 2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) Project Objective: Skilled nursing facilities (SNFs) will implement the evidence based INTERACT program developed

More information

How are Health Home Services Provided to the Medically Needy?

How are Health Home Services Provided to the Medically Needy? Id: NEW YORK State: New York Health Home Services Effective Date- January 1, 2012 SPA includes both Categorically Needy and Medically Needy Beneficiaries- check box 3.1 - A: Categorically Needy View Attachment

More information

Community Care of North Carolina. Statewide program for managing Carolina Access recipients

Community Care of North Carolina. Statewide program for managing Carolina Access recipients Community Care of North Carolina Statewide program for managing Carolina Access recipients Key Goals Improve access to, quality of, and coordination of care for Carolina Access Medicaid patients. By doing

More information

Transition from Targeted Case Management (TCM) to Health Home Care Management and non-medicaid funded Care Management (CM)

Transition from Targeted Case Management (TCM) to Health Home Care Management and non-medicaid funded Care Management (CM) Transition from Targeted Case Management (TCM) to Health Home Care Management and non-medicaid funded Care Management (CM) Interim Instruction: February 21, 2012 The New York State (NYS) Office of Mental

More information

Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: December 6, 2013

Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: December 6, 2013 Assertive Community Treatment (ACT) Providing Health Home Care Management Interim Instruction: December 6, 2013 Introduction The OMH licensed and regulated Assertive Community Treatment Program (ACT) will

More information

Accountable Care Organization Workgroup Glossary

Accountable Care Organization Workgroup Glossary Accountable Care Organization Workgroup Glossary Accountable care organization (ACO) a group of coordinated health care providers that care for all or some of the health care needs of a defined population.

More information

Stuart Levine MD MHA Corporate Medical Director, HealthCare Partners Assistant Clinical Professor, Internal Medicine and Psychiatry, UCLA David

Stuart Levine MD MHA Corporate Medical Director, HealthCare Partners Assistant Clinical Professor, Internal Medicine and Psychiatry, UCLA David Stuart Levine MD MHA Corporate Medical Director, HealthCare Partners Assistant Clinical Professor, Internal Medicine and Psychiatry, UCLA David Geffen School of Medicine 1 HealthCare Partners Delivery

More information

Post-Master's Adult Nurse Practitioner (AGNP)

Post-Master's Adult Nurse Practitioner (AGNP) : Post-Master's Adult Nurse Practitioner (AGNP) University of Florida College of Nursing M. Dee Williams, PhD, RN willimd@ufl.edu 1 Table of Contents A. Rationale... 3 B. Mission... 3 C. Student Learning

More information

DIABETES DISEASE MANAGEMENT PROGRAM DESCRIPTION FY11 FY12

DIABETES DISEASE MANAGEMENT PROGRAM DESCRIPTION FY11 FY12 DIABETES DISEASE MANAGEMENT PROGRAM DESCRIPTION FY11 FY12 TABLE OF CONTENTS 1. INTRODUCTION.3 2. SCOPE........3 3. PROGRAM STRUCTURE...4 3.1. General Educational Interventions.....4 3.2. Identification

More information

Arkansas Behavioral Health Home State Plan Amendment. Draft - 03/11/14

Arkansas Behavioral Health Home State Plan Amendment. Draft - 03/11/14 Arkansas Behavioral Health Home State Plan Amendment Draft - 03/11/14 NOTE: Bolded text within document denotes required health home language by the Centers for Medicare and Medicaid Services (CMS) with

More information

Administrative Code. Title 23: Medicaid Part 223

Administrative Code. Title 23: Medicaid Part 223 Title 23: Medicaid Administrative Code Title 23: Medicaid Part 223 Table of Contents Table of Contents Title 23: Medicaid... 1 Table of Contents... 1 Title 23: Division of Medicaid... 1 Part 223: Early

More information

UnitedHealthcare Plan of the River Valley, Inc. Iowa Medicaid Level of Care Guidelines. Supported Employment Individual Employment Habilitation

UnitedHealthcare Plan of the River Valley, Inc. Iowa Medicaid Level of Care Guidelines. Supported Employment Individual Employment Habilitation UnitedHealthcare Plan of the River Valley, Inc. Iowa Medicaid Level of Care Guidelines Effective Date: March, 2016 Revision Date: Supported Employment Individual Employment Habilitation Home and Community

More information

Unity Point Health PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD

Unity Point Health PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD Unity Point Health PROBLEM LISTS IN THE ELECTRONIC HEALTH RECORD Introduction The problem list is a critical part of electronic documentation and serves as a communication tool between all care providers.

More information

Patient Centered Medical Home: An Approach for the Health Plan

Patient Centered Medical Home: An Approach for the Health Plan : An Approach for the Health Plan By Marissa A. Harper and JoAnn E. Balara Excellence in healthcare consulting The Medical Home Concept Works Recent Medicare demonstration projects on Patient Centered

More information

Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services.

Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services. Domain 3 Projects 3.a.i Integration of Primary Care and Behavioral Health Services Project Objective: Integration of mental health and substance abuse with primary care services to ensure coordination

More information

February 26, 2016. Dear Mr. Slavitt:

February 26, 2016. Dear Mr. Slavitt: February 26, 2016 Mr. Andy Slavitt Acting Administrator Centers for Medicare & Medicaid Services (CMS) Department of Health and Human Services Attention: CMS-3321-NC PO Box 8016 Baltimore, MD 21244 Re:

More information

Health Care Homes Certification Assessment Tool- With Examples

Health Care Homes Certification Assessment Tool- With Examples Guidelines: Health Care Homes Certification Assessment Form Structure: This is the self-assessment form that HCH applicants should use to determine if they meet the requirements for HCH certification.

More information

Provider Notification Obstetrical Billing

Provider Notification Obstetrical Billing Provider Notification Obstetrical Billing Date of Notification September 1, 20 Revision Date September 17, 2015 Plans Affected Mercy Care Plan and Mercy Care Long Term Care Plan Referrals As outlined in

More information

Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment

Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Person-Centered Nurse Care Management in Home Based Care: Impact on Well-Being and Cost Containment Donna Zazworsky, RN, MS, CCM, FAAN Vice President: Community Health and Continuum Care Carondelet Health

More information

Health Home Program (Section 2703) Iowa Medicaid Enterprise. Marni Bussell Project Manager December 13, 2013

Health Home Program (Section 2703) Iowa Medicaid Enterprise. Marni Bussell Project Manager December 13, 2013 Health Home Program (Section 2703) Iowa Medicaid Enterprise Marni Bussell Project Manager December 13, 2013 1 Two Health Home Programs: Same Triple Aim Goals Chronic Condition Health Home: Primary Care

More information

CPT only copyright 2014 American Medical Association. All rights reserved. 10/10/2014 Page 537 of 593

CPT only copyright 2014 American Medical Association. All rights reserved. 10/10/2014 Page 537 of 593 Measure #391 (NQF 0576): Follow-Up After Hospitalization for Mental Illness (FUH) National Quality Strategy Domain: Communication and Care Coordination 2015 PHYSICIAN QUALITY REPTING OPTIONS F INDIVIDUAL

More information

Medicare Managed Care Manual Chapter 5 - Quality Assessment

Medicare Managed Care Manual Chapter 5 - Quality Assessment Medicare Managed Care Manual Chapter 5 - Quality Assessment Transmittals Issued for this Chapter Table of Contents (Rev. 117, 08-08-14) 10 Introduction 20 Medicare Quality Improvement Program 20.1 Chronic

More information

CHAPTER 7: UTILIZATION MANAGEMENT

CHAPTER 7: UTILIZATION MANAGEMENT OVERVIEW The Plan s Utilization Management (UM) program is collaboration with providers to promote and document the appropriate use of health care resources. The program reflects the most current utilization

More information

DIRECT CARE CLINIC DASHBOARD INDICATORS SPECIFICATIONS MANUAL Last Revised 11/20/10

DIRECT CARE CLINIC DASHBOARD INDICATORS SPECIFICATIONS MANUAL Last Revised 11/20/10 DIRECT CARE CLINIC DASHBOARD INDICATORS SPECIFICATIONS MANUAL Last Revised 11/20/10 1. ACT Fidelity 2. ISP Current 3. ISP Quality 4. Recipient Satisfaction 5. Staffing Physician 6. Staffing Case Manager

More information

Advancing Health Equity. Through national health care quality standards

Advancing Health Equity. Through national health care quality standards Advancing Health Equity Through national health care quality standards TABLE OF CONTENTS Stage 1 Requirements for Certified Electronic Health Records... 3 Proposed Stage 2 Requirements for Certified Electronic

More information

BlueAdvantage SM Health Management

BlueAdvantage SM Health Management BlueAdvantage SM Health Management BlueAdvantage member benefits include access to a comprehensive health management program designed to encompass total health needs and promote access to individualized,

More information

SECTION 2 TARGETED CASE MANAGEMENT FOR THE CHRONICALLY MENTALLY ILL. Table of Contents

SECTION 2 TARGETED CASE MANAGEMENT FOR THE CHRONICALLY MENTALLY ILL. Table of Contents SECTION 2 TARGETED CASE MANAGEMENT FOR THE CHRONICALLY MENTALLY ILL Table of Contents 1 GENERAL POLICY... 2 1-1 Authority... 2 1-2 Definitions... 2 1-3 Target Group... 2 1-4 Qualified Targeted Case Management

More information

MaineCare Value Based Purchasing Initiative

MaineCare Value Based Purchasing Initiative MaineCare Value Based Purchasing Initiative The Accountable Communities Strategy Jim Leonard, Deputy Director, MaineCare Peter Kraut, Acting Accountable Communities Program Manager Why Value-Based Purchasing

More information

Governor s Access Plan for the Seriously Mentally Ill (GAP)

Governor s Access Plan for the Seriously Mentally Ill (GAP) Department of of Medical Medical Assistance Assistance Services Services Governor s Access Plan for the Seriously Mentally Ill (GAP) Sherry Confer, Special Projects Manager Virginia Department Of Medical

More information

Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015

Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015 Leveraging the Continuum to Avoid Unnecessary Utilization While Improving Quality Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015 Karim A. Habibi, FHFMA, MPH, MS Senior

More information

Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases

Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases Johns Hopkins HealthCare LLC: Care Management and Care Coordination for Chronic Diseases Epidemiology Over 145 million people ( nearly half the population) - suffer from asthma, depression and other chronic

More information

Physician Practice Connections Patient Centered Medical Home

Physician Practice Connections Patient Centered Medical Home Physician Practice Connections Patient Centered Medical Home Getting Started Any practice assessing its ability to achieve NCQA Physician Recognition in PPC- PCMH is taking a bold step toward aligning

More information

Test Content Outline Effective Date: October 25, 2014. Medical-Surgical Nursing Board Certification Examination

Test Content Outline Effective Date: October 25, 2014. Medical-Surgical Nursing Board Certification Examination Board Certification Examination There are 175 questions on this examination. Of these, 150 are scored questions and 25 are pretest questions that are not scored. Pretest questions are used to determine

More information

Special Needs Plan Model of Care 101

Special Needs Plan Model of Care 101 Special Needs Plan Model of Care 101 What is a Special Needs Plan? First of all it s a Medicare MA-PD, typically an HMO Consists of Medicare enrollees who meet special eligibility requirements In our case

More information

Special Needs Programs Overview. Diabetes

Special Needs Programs Overview. Diabetes Special Needs Programs Overview Brand New Day health plan has several special programs for individuals with one or more of the following chronic conditions: Diabetes, Dementia, or Mental Illness. Below

More information

A Review of the Beacon Health Options Clinical Case Management

A Review of the Beacon Health Options Clinical Case Management Clinical 3.50 CASE MANAGEMENT 3.504 Intensive Case Management (Child/Adolescent) Description of Services: Intensive Case Management provides for a single point of coordination/accountability in managing

More information

GUILDNET HEALTH ADVANTAGE MODEL OF CARE

GUILDNET HEALTH ADVANTAGE MODEL OF CARE GUILDNET HEALTH ADVANTAGE MODEL OF CARE Introduction: GuildNet Health Advantage is a dual eligible SNP. The plan provides a rich benefit package to beneficiaries eligible for Medicare and full Medicaid

More information

Department of Health Services. Behavioral Health Integrated Care. Health Home Certification Application

Department of Health Services. Behavioral Health Integrated Care. Health Home Certification Application Department of Health Services Behavioral Health Integrated Care Health Home Certification Application (Langlade, Lincoln, and Marathon Counties) December 18, 2013 1 Behavioral Health Integrated Care Health

More information

Policy and Procedure Manual

Policy and Procedure Manual Policy and Procedure Manual Resident Assessment (RA) Table of Contents RA-01 RA-02 RA-03 RA-04 RA-05 RA-06 RA-07 RA-08 RA-09 RA-10 RA-11 RA-12 Physical Health Services Dental Services Initial Nursing Summary

More information

What is Passport to Health?

What is Passport to Health? What is Passport to Health? Passport to Health is the Montana Medicaid/HMK Plus primary care case management program Mission Statement: Our mission is to manage the delivery of health care to people with

More information

2013 IHCP 2 nd Quarter Provider Workshop Indiana Care Select Program

2013 IHCP 2 nd Quarter Provider Workshop Indiana Care Select Program 2013 IHCP 2 nd Quarter Provider Workshop Indiana Care Select Program This presentation can be downloaded at: www.advantageplan.com/advcareselect http://www.mdwise.org/providers-workshops.html DOC_43_13

More information

DSRIP, Shared Savings, and the Path towards Value Based Payment

DSRIP, Shared Savings, and the Path towards Value Based Payment Redesign Medicaid in New York State DSRIP, Shared Savings, and the Path towards Value Based Payment New York State Department of Health New York, New York The DSRIP Challenge Transforming the Delivery

More information

RE: CMS-3819-P; Medicare and Medicaid Programs; Conditions of Participation for Home Health Agencies

RE: CMS-3819-P; Medicare and Medicaid Programs; Conditions of Participation for Home Health Agencies January 6, 2015 Marilyn Tavenner Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445 G Attention: CMS-3819-P Hubert H. Humphrey Building, 200 Independence

More information

TABLE OF CONTENTS. Medical Management. BCBSIL Provider Manual Rev 10/13 1

TABLE OF CONTENTS. Medical Management. BCBSIL Provider Manual Rev 10/13 1 TABLE OF CONTENTS Medical Management... 2 Benefit Pre-certification... 2 Benefit Pre-certification for Inpatient and Ancillary Medical Services... 2 Benefit Pre-certification for Outpatient Medical/Surgical

More information

ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT

ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT Accountable Care Analytics: Developing a Trusted 360 Degree View of the Patient Introduction Recent federal regulations have

More information

Medicaid Health Homes Emerging Models and Implications for Solutions to Chronic Homelessness

Medicaid Health Homes Emerging Models and Implications for Solutions to Chronic Homelessness Medicaid Health Homes Emerging Models and Implications for Solutions to Chronic Homelessness November 2012 Several states have begun implementing the new Medicaid health home benefit created by the Affordable

More information