Common use of Transitional Care Management Clause in Contracts

Transitional Care Management. i. The Contractor shall develop a methodology for identifying enrollees being discharged from a care facility who are at risk of readmissions and other poor outcomes. This methodology may take into account: 1. Frequency, duration and acuity of inpatient, Skilled Nursing Facility (SNF) and LTSS admissions or ED visits; 2. Discharges and pending discharges from inpatient behavioral health services, facility-based crisis services; NICU discharges and pending discharges; and 3. Identification of patients by severity of condition, medications, risk score, healthy opportunities, and other factors the Contractor may prioritize. ii. As part of transitional care management, the Contractor shall: 1. Outreach to the Member’s assigned PCP and other medical providers for knowledge transfer and smooth transition of care; 2. Outreach to provider to inquire about receipt of discharge plan; 3. Make best effort to obtain copy of discharge plan and if received, review with enrollee; 4. Outreach to practice regarding scheduling outpatient follow-up visit within a time frame appropriate to the specific circumstances for that enrollee; 5. Conduct medication management, including reconciliation, and support medication adherence; 6. Ensure that a care manager is assigned to manage the transition; 7. Encourage the enrollee to schedule a follow-up visit with their PCP, if discharged to home, within fourteen (14) Calendar Days of discharge; 8. Ensure that the assigned care manager follows-up with the enrollee following discharge; and 9. Develop a protocol for determining the appropriate timing and format of such outreach. iii. The Contractor shall ensure that Comprehensive Assessment is completed and current for all Members upon completion of transitional care management, including re-assessment for Members already assigned to care management as needed. iv. The Department shall ensure the Contractor has access to an ADT data from NCHIEA that identifies when enrollees are admitted, discharged, or transferred from one care setting to another, in real time or near real time. v. When the Contractor receives notice of any of the following alerts, the Contractor will respond promptly, and will attempt to follow-up with the enrollee as appropriate to discuss potential outpatient services needed: 1. Same-day or next-day outreach for Contractor-designated high-risk subsets of the population with ED visit; 2. Same-day or next-day outreach for Contractor-designated high-risk subsets of the population, such as children with special health care needs discharged from the hospital; and 3. Additional outreach within several days after the alert to address outpatient needs (e.g. to assist with scheduling appropriate follow up visits or medication reconciliations post discharge). vi. When the Contractor receives notice an enrollee has been discharged from a LTSS setting, the Contractor shall attempt to contact the LTSS care managers or healthcare providers for that enrollee to gather relevant information about the enrollee’s prior care.