Needs-Stratification. Needs stratification aims to align the member’s overall medical and social needs with the most appropriate level of care management for that member, including WICT for highest needs members. In order to achieve this alignment, HMOs must use individual member-level needs stratification as an input for developing individual care management plans, and for using those plans to provide care management for the members. The HMO’s care management team will be responsible for conducting and validating the needs stratification results. The HMO must have established processes, systems, tools, models, and administrative and clinical staff to conduct the following tasks related to needs stratification:
Needs-Stratification. Needs stratification aims to align the member’s overall medical and social needs with the most appropriate level of care management for that member, including WICT for highest needs members. In order to achieve this alignment, HMOs must use individual member-level needs stratification as an input for developing individual care management plans, and for using those plans to provide care management for the members. The HMO’s care management team will be responsible for conducting and validating the needs stratification results. The HMO must have established processes, systems, tools, models, and administrative and clinical staff to conduct the following tasks related to needs stratification: Proactively stratify individual members upon enrollment, using clinical, social, administrative and other relevant data collected during Information Gathering of the care management process. Use the stratification information for each member to assign individual members to the most appropriate care management strata, including the WICT for the highest-needs members. Prior to assigning a member to the WICT, HMOs must confirm that the member is able to participate in the intensive short-term intervention and the HMO is able to meet the WICT functional requirements for that member. Use stratification information as an input to develop individualized comprehensive care plans. Use the care plans to provide the most appropriate care management for individual members based on their needs. Periodically reassess whether the members are assigned to the most appropriate strata, based on changes in their overall medical and social needs. Continuously monitor and enhance HMO’s stratification methods for improving the health outcomes for members. If a HMO’s needs stratification process results in over 5% of its monthly SSI caseload being identified as high needs and enrolled in a WICT, the HMO must notify DHS within 15 calendar days of the next calendar month. The Department will discuss with the HMO any approved continued high-WICT enrollment or any changes the HMO makes to the needs stratification process and/or care management model.
