Member name, address, phone number, DOB, MC400 Member ID, MA Recipient Number
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1 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 Recipient Number Member Engagement Status Status = Consent, Enrolled, Passive- UTR, Passive-Opt out; date provided Other Needs: Needs TTY Line/Language Line English not primary language Primary Language: Lead Physical and Behavioral Health Staff UPMC Health Plan: name of HP staff CCBH: name of CCBH staff Member Contacts Primary caregiver, Community Case Manager/CTT, CCBH Contact ; Personal Wellness Advocate Display: category, contact name, relationship, phone number(s) Primary Care Provider on Record Behavioral Health Provider on Record Chronic Medical Conditions Behavioral Health Diagnoses Inpatient Utilization Admission date, discharge date, LOS, facility, admit diagnosis (exclude D&A) Display rolling 12 month period Emergency Department Utilization Admission date, facility, diagnosis (exclude D&A) Display rolling 12 month period 1
2 Care Coordination Triggers and Behavioral Health Needs Result Community Care Most PHQ2 Screening Result Health Plan Most Member outreach for depression Coordination of care for depression Educational materials provided for depression Crisis recovery plan in place Educated on Resolve Physical Health Needs (self-identified) Asthma COPD/Emphysema Diabetes Heart Disease Heart Failure High Blood Pressure High Cholesterol Kidney Failure Memory Problems Sickle Cell Other Poor/Very Poor Health Status Member enrolled in case management (excl. EPSDT, MTM) Educational materials provided to address DM needs Member has self-management plan Has symptom response plan for physical health Educated on 24/7 nurse advice line Most 2
3 Medical Home/Access to Care Needs Does not see PH Provider regularly Does not see BH Provider regularly Facilitate PCP assignment Coordinate care with PH provider due to insufficient follow-up Facilitate behavioral health provider assignment Coordinate care with BH provider due to insufficient follow-up Transportation Has transportation needs Provided transportation resources Emergency Department Visits Has frequent ED Visits Assessed regarding frequent ED use Facilitate provider communication Inpatient Admissions Has frequent PH Readmissions Has frequent BH Readmissions 3
4 Assessed regarding PH hospital admissions Assessed regarding BH hospital admissions Referral to Mobile CM Enrolled in Transitions Program Member has post-discharge follow up appointment with provider Assessed for referral to more intensive BH treatment programs Reviewed crisis plan Medication Concerns Physical Health Medication compliance issue Behavioral Health Medication compliance issue Difficulty obtaining medication Antipsychotic adherence post hospital discharge Antipsychotic compliance issue Medication compliance issue due to side effects Lack of understanding related to medication use Medication reconciliation completed Medication intervention by pharmacist during review Referral to pharmacy for noncompliance issue Contacted provider for noncompliance issue BH provider gave instructions on managing symptoms Support Needs Inadequate caregiver support ADL/IADL needs 4
5 Provided education regarding caregiver support needs community resources for caregiver support needs caregiver support needs Provided education regarding ADL/IADL needs community resources for ADL/IADL needs ADL/IADL needs Assist member with care coordination for ADL/IADL needs Environmental/Safety Needs Safety issued identified in home Homeless Inadequate housing Possible domestic violence Fall Risk Lives alone Provided education regarding environmental safety issue community resources for environmental safety issue environmental safety issue Assist member with care coordination for environmental safety issue Referral to homeless shelter or program Provided education for possible abuse community resources for possible abuse possible abuse 5
6 Assist member with care coordination for possible abuse Assist member in developing a safety plan Coordinate home safety assessment for fall prevention Coordinate medication review for fall prevention Provided education for fall prevention Assist member with care coordination for fall prevention Lifestyle Issues Tobacco use Nutritional need Overweight Exercise need Referral for tobacco cessation Referral to weight loss program Referral to nutrition program Referral to exercise program Miscellaneous Issues Communication/literacy needs identified Member has advanced directive Member has power of attorney Referred to appropriate community resources for communication/literacy needs Assisted with coordination of care for communication/literacy needs Mailed advanced directive information to member 6
7 Integrated Care Team Activity Activity With Note 7
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