Common use of Complex Case Management Clause in Contracts

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. Xxx X0X), 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 inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level. The Contractor shall document the number of persons with conditions of interest, outbound telephone calls to providers and members, telephone contacts to members and providers, category of intervention, intervention delivered, mailings and website hits. Utilization statistics on hospitalizations, emergency services, primary care and specialty care should be documented and trended from baseline. The Contractor’s case management services shall be coordinated with the Right Choices Program for members qualifying for the Right Choices Program. However, the Right Choices Program shall not be considered a replacement for care management or complex case management.

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 a member’s designation as medically frail, identification through the health needs screening as having special care needs, a condition of interest named above and/or above, or a chronic or co-morbid disease utilization history and/or member request that indicates the need for real- 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 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 care 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. Case 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. Xxx X0X), pharmacy refill reminders, tobacco cessation and education regarding use of primary care and emergency services. Materials can be delivered through postal and electronic directdirect- to-to- consumer contacts, as well as web-based education materials inclusive of clinical practice guidelines. Materials shall be developed at the fifth grade reading level. The Contractor shall document the number of persons with conditions of interest, outbound telephone calls to providers and members, telephone contacts to members and providers, category of intervention, intervention delivered, mailings and website hits. Utilization statistics on hospitalizations, emergency services, primary care and specialty care should be documented and trended from baseline. The Contractor’s case care management services shall be coordinated with the Right Choices Program for members qualifying for the Right Choices Program. However, the Right Choices Program shall not be considered a replacement for care management or complex case management.