Complex Case Management Clause Samples
Complex Case Management. The Contractor’s protocol for referring members to complex case management shall be reviewed by OMPP and shall be based on member needs identified through the health needs screening as having special care needs, a condition of interest named above and/or a chronic or co-morbid disease utilization history that indicates the need for real- time, proactive intervention. Persons with clinical medical training shall be required to develop the member’s care plan. The Medical Director shall be available to consult with the clinicians on the case management team as needed to develop the care plans for high risk cases. Care plans developed by the Contractor shall include clearly stated health care goals to address the medical, social, educational, and other services needed by the individual and defined milestones to document progress, clearly defined accountability and responsibility and timely, thorough review with appropriate corrections ("course changes") as indicated. The Contractor’s case management services and care plan development shall involve the active management of the member and his/her group of health care providers, including physicians, medical equipment, transportation and pharmacy to help link the member with providers or programs capable of helping the member achieve the defined goals of the care plan. The member’s health care providers shall be included in the development and execution of member care plans. Care plans and care management shall take into account co-morbidities being jointly managed and executed, as separate care plans for each medical problem in the same member may fragment care and add to the potential of missing interactive factors. The Contractor shall contact members telephonically and in-person as indicated by their need. Case managers should engage in care conferences with the member’s health care providers, as necessary. Members shall receive the same educational materials delivered to those persons receiving case management including direct consumer contacts in order to assist members with scheduling, location of specialists and specialty services, transportation needs, 24-Hour Nurse Call Line, general preventive (e.g. mammography) and disease specific reminders (e.g. ▇▇▇ ▇▇▇), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. Materials can be delivered through postal and electronic direct-to- consumer contacts, as well as web-based education materials inclusi...
Complex Case Management. Contractor will develop methods to identify Enrollees who may benefit from complex case management services, using the risk stratification and HRA results (see sections 2.8.1 and 2.
Complex Case Management. The Contractor’s protocol for referring members to complex case management shall be reviewed by OMPP and shall be based on a member’s designation as medically frail, identification through the health needs screening as having special care needs, a condition of interest named above, or a chronic or co-morbid disease utilization history and/or member request that indicates the need for real-time, proactive intervention. Persons with clinical medical training shall be required to develop the member’s care plan. The Medical Director shall be available to consult with the clinicians on the care management team as needed to develop the care plans for high risk cases. Care plans developed by the Contractor shall include clearly stated health care goals to address the medical, social, educational, and other services needed by the individual and defined milestones to document progress, clearly defined accountability and responsibility and timely, thorough review with appropriate corrections ("course changes") as indicated. The Contractor’s case management services and care plan development shall involve the active management of the member and his/her group of health care providers, including physicians, medical equipment, transportation and pharmacy to help link the member with providers or programs capable of helping the member achieve the defined goals of the care plan. The member’s health care providers shall be included in the development and execution of member care plans. Care plans and case management shall take into account co-morbidities being jointly managed and executed, as separate care plans for each medical problem in the same member may fragment care and add to the potential of missing interactive factors. The Contractor shall contact members telephonically and in-person as indicated by their need. Care managers should engage in care conferences with the member’s health care providers, as necessary. Members shall receive the same educational materials delivered to those persons receiving case management including direct consumer contacts in order to assist members with scheduling, location of specialists and specialty services, transportation needs, 24-Hour Nurse Call Line, general preventive (e.g. mammography) and disease specific reminders (e.g. ▇▇▇ ▇▇▇), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. Materials can be delivered through postal and electronic direct- to-consumer contac...
Complex Case Management. The CONTRACTOR shall provide a Complex Case Management Program (CCMP) for eligible members, identified by criteria listed in Section A.2.
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
Complex Case Management. The systematic coordination and assessment of care and services provided to members who have experienced a critical event or diagnosis that requires the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services.
Complex Case Management. The Contractor’s protocol for referring members to complex case management shall be reviewed by OMPP and shall be based on member needs identified through the health needs screening as having special care needs, a condition of interest named above and/or a chronic or co-morbid disease utilization history that indicates the need for real-time, proactive intervention. Persons with clinical medical training shall be required to develop the member’s care plan. The Medical Director shall be available to consult with the clinicians on the case management team as needed to develop the care plans for high risk cases. Care plans developed by the Contractor shall include clearly stated health care goals, defined milestones to document progress, clearly defined accountability and responsibility and timely, thorough review with appropriate corrections ("course changes") as