Common use of Care Management Elements Clause in Contracts

Care Management Elements. As part of the Care Management Model, the following must be provided for each member: a. Health Needs Assessment Screening (BadgerCare Plus Childless Adults only) 1) HMOs shall conduct an initial Health Needs Assessment (HNA) Screening for Childless Adults (CLA) members within 60 days of enrollment in the HMO. 2) The HMO must perform an initial Screening for newly enrolled CLA members, and CLA members that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment. 3) The initial HNA Screening shall be conducted by appropriately qualified staff via methods that may include telephonic contact, mailings, interactive web tools, or encounters in person with screeners or health care providers. 4) Initial HNA Screening Elements – At a minimum, the HNA screening must address the following elements: i. Urgent medical and behavioral symptoms (i.e. dyspnea, rapid weight gain/loss, syncope, suicidal ideations, psychotic break); ii. Members’ perception of their general well-being; iii. Identify usual sources of care (e.g. primary care provider, clinic, specialist and dental provider); iv. Frequency in use of emergency and inpatient services; v. History of chronic physical and mental health illness (e.g. respiratory disease, heart disease, stroke, diabetes/pre-diabetes, back pain and musculoskeletal disorders, cancer, overweight/obesity, severe mental illness, substance abuse); vi. Number of prescription medications used monthly; vii. Socioeconomic barriers to care (e.g. stability of housing, reliable transportation, nutrition/food resources, availability of family/caregivers to provide support); viii. Behavioral and medical risk factors including member’s willingness to change their behavior such as: 1. Symptoms of depression 2. Alcohol consumption and substance abuse 3. Tobacco use ix. Weight (e.g. using BMI or waist circumference) and blood pressure indicators. 5) As part of the HNA Screening process, HMOs are encouraged to assist members in identifying a primary care provider. 6) Based on member’s responses to the HNA Screening, HMOs shall conduct additional chronic or acute illness assessments as needed and identify members that may need additional care coordination.

Care Management Elements. As part of the Care Management Model, the following must be provided for each member: a. Health Needs Assessment Screening (BadgerCare Plus Childless Adults only) 1) HMOs shall conduct an initial Health Needs Assessment (HNA) Screening for Childless Adults (CLA) members within 60 days of enrollment in the HMO. 2) The HMO must perform an initial HNA Screening for newly enrolled CLA members, and CLA members that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment. 3) The initial HNA Screening shall be conducted by appropriately qualified staff via methods that may include telephonic contact, mailings, interactive web tools, or encounters in person with screeners or health care providers. 4) Initial HNA Screening Elements – At a minimum, the HNA screening must address the following elements: i. Urgent medical and behavioral symptoms (i.e. dyspnea, rapid weight gain/loss, syncope, suicidal ideations, psychotic break); ii. Members’ perception of their general well-being; iii. Identify usual sources of care (e.g. primary care provider, clinic, specialist and dental provider); iv. Frequency in use of emergency and inpatient services; v. History of chronic physical and mental health illness (e.g. respiratory disease, heart disease, stroke, diabetes/pre-diabetes, back pain and musculoskeletal disorders, cancer, overweight/obesity, severe mental illness, substance abuse); vi. Number of prescription medications used monthly; vii. Socioeconomic barriers to care (e.g. stability of housing, reliable transportation, nutrition/food resources, availability of family/caregivers to provide support); viii. Behavioral and medical risk factors including member’s willingness to change their behavior such as: 1. Symptoms of depression 2. Alcohol consumption and substance abuse 3. Tobacco use ix. Weight (e.g. using BMI or waist circumference) and blood pressure indicators. 5) As part of the HNA Screening process, HMOs are encouraged to assist members in identifying a primary care provider. 6) Based on member’s responses to the HNA Screening, HMOs shall conduct additional chronic or acute illness assessments as needed and identify members that may need additional care coordination.

Care Management Elements. As part of the Care Management Model, the following must be provided for each member: a. Health Needs Assessment Screening (BadgerCare Plus Childless Adults only) 1) HMOs shall conduct an initial Health Needs Assessment (HNA) Screening for Childless Adults (CLA) members within 60 days of enrollment in the HMO. 2) The HMO must perform an initial Screening for newly enrolled CLA members, and CLA members that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment. 3) The initial HNA Screening shall be conducted by appropriately qualified staff via methods that may include telephonic contact, mailings, interactive web tools, or encounters in person with screeners or health care providers. 4) Initial HNA Screening Elements – At a minimum, the HNA screening must address the following elements: i. Urgent medical and behavioral symptoms (i.e. dyspneashortness of breath, rapid weight gain/loss, syncope, suicidal ideations, psychotic break); ii. Members’ perception of their general well-being; iii. Identify usual sources of care (e.g. primary care provider, clinic, specialist and dental provider); iv. Frequency in use of emergency and inpatient services; v. History of chronic physical and mental health illness (e.g. respiratory disease, heart disease, stroke, diabetes/pre-diabetes, back pain and musculoskeletal disorders, cancer, overweight/obesity, severe mental illnessillness(es), substance abuse); vi. Number of prescription medications used monthly; vii. Socioeconomic barriers to care (e.g. stability of housing, reliable transportation, nutrition/food resources, availability of family/caregivers to provide support); viii. Behavioral and medical risk factors including member’s willingness to change their behavior such as: 1. Symptoms of depression 2. Alcohol consumption and substance abuse abuse 3. Tobacco use ix. Weight Overweight and obesity (e.g. using BMI or waist circumference) and high/elevated blood pressure indicatorspressure. 5) As part of the HNA Screening process, HMOs are encouraged to assist members in identifying a primary care provider. 6) Based on member’s responses to the HNA Screening, HMOs shall conduct additional chronic or acute illness assessments as needed and identify members that may need additional care coordination. b. Comprehensive Assessments (Medicaid SSI only) 1) HMOs shall conduct a comprehensive assessment for each SSI Managed Care member within 60 days of enrollment in the HMO. 2) The HMO must perform a comprehensive assessment for newly enrolled SSI Managed Care members, and members that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment. 3) The comprehensive assessment shall be conducted by a care coordinator or an appropriately qualified health care professional via face-to-face or telephonic contact with the member and/or legal guardian. 4) The assessment process shall be comprehensive and be consistent with the following principles:  Be member-centric which includes: o An evaluation of the member’s health history and health status. o Identifying the member’s recovery goals and understanding of options for treatment. o Addressing the strengths, needs, preferences, values and lifestyle described by the member. o Identifying the cultural and environmental supports of the member.  Be updated as new information becomes available or with a change in the member’s condition.  In order to be comprehensive, the assessment shall include the following elements at a minimum: o History of chronic physical and mental health illness (e.g. respiratory disease, heart disease, stroke, diabetes/pre-diabetes, back pain and musculoskeletal disorders, cancer, overweight/obesity, all mental health and substance abuse disorders); o Demographic information and socioeconomic barriers to care (including ethnicity, education, living situation/housing, transportation, nutrition/food, communication and cognition, overnight care and employment); o Activities of daily living (including bathing, dressing and eating); o Instrumental activities of daily living (including medication management, money management and transportation); o Indirect supports (family, social and community network); o General health and life goals. 5) As part of the assessment completion process, HMOs are encouraged to assist members in identifying a primary care provider. 6) Based on member’s responses to the comprehensive assessment, HMOs shall conduct additional chronic or acute illness assessments as needed and identify members that may need intensive care coordination. c. Care Plan (SSI Medicaid only) After HMOs conduct the comprehensive assessment, the care coordinator or other qualified health care professional must develop a care plan for Medicaid SSI members within 30 days of completion of the assessment. 1) The care plan must be member-centric, be culturally sensitive, include appropriate medical, behavioral health, dental and social services and be consistent with the primary care provider’s clinical treatment plan. 2) The care plan must be developed in consultation with the member and/or the member’s legal guardian, with opportunity for the member to provide input. Member participation and agreement with the care plan process must be documented by the HMO. 3) The care plan must be made available to the member, the member’s primary care provider and to other service providers as appropriate and with consent of the member. 4) The HMO is responsible for delivery of all Medicaid SSI covered services deemed medically necessary except for services for which the member may exercise his or her right to refuse care.  In the event that Medicaid SSI covered services specified in the care plan do not occur, the HMO records must document the reasons why care was not provided.  For non-covered services, the HMO must assure that the members are referred to appropriate community resources. d. Service Delivery (BadgerCare Plus – Childless Adults and SSI Medicaid) The HMO must coordinate and provide Medicaid-covered medically necessary services to members in accordance with the needs identified in the HNA Screening for the CLA population as well as the comprehensive assessment and the Care Plan for the SSI Managed Care population. The HMO care coordinator or other professional staff shall follow-up regularly with the member to determine if services provided best addressed their needs.

Care Management Elements. As part of the Care Management Model, the following must be provided for each member: a. Health Needs Assessment Screening (BadgerCare Plus Childless Adults only) 1) HMOs shall conduct an initial Health Needs Assessment (HNA) Screening for Childless Adults (CLA) members within 60 days of enrollment in the HMO. 2) The HMO must perform an initial HNA Screening for newly enrolled CLA members, and CLA members that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment. 3) The initial HNA Screening shall be conducted by appropriately qualified staff via methods that may include telephonic contact, mailings, interactive web tools, or encounters in person with screeners or health care providers. 4) Initial HNA Screening Elements – At a minimum, the HNA screening must address the following elements: i. Urgent medical and behavioral symptoms (i.e. dyspnea, rapid weight gain/loss, syncope, suicidal ideations, psychotic break); ii. Members’ perception of their general well-being; iii. Identify usual sources of care (e.g. primary care provider, clinic, specialist and dental provider); iv. Frequency in use of emergency and inpatient services; v. History of chronic physical and mental health illness (e.g. respiratory disease, heart disease, stroke, diabetes/pre-diabetes, back pain and musculoskeletal disorders, cancer, overweight/obesity, severe mental illness, substance abuse); vi. Number of prescription medications used monthly; vii. Socioeconomic barriers to care (e.g. stability of housing, reliable transportation, nutrition/food resources, availability of family/caregivers to provide support); viii. Behavioral and medical risk factors including member’s willingness to change their behavior such as: 1. Symptoms of depression 2. Alcohol consumption and substance abuse 3. Tobacco use ix. Weight (e.g. using BMI or waist circumference) and blood pressure indicators. 5) As part of the HNA Screening process, HMOs are encouraged to assist members in identifying a primary care provider. 6) Based on member’s responses to the HNA Screening, HMOs shall conduct additional chronic or acute illness assessments as needed and identify members that may need additional care coordination.