Care Plan Characteristics. After completing the initial Screening and the Information Gathering processes, the care management team or the WICT must develop and implement a Comprehensive Care Plan in coordination with the member that prioritizes interventions based on the member’s medical, mental, behavioral, dental health and other social needs. The Comprehensive Care Plan must have the following characteristics:
Care Plan Characteristics. After completing the initial Screening and the Information Gathering processes, the care management team or the WICT must develop and implement a Comprehensive Care Plan in coordination with the member that prioritizes interventions based on the member’s medical, mental, behavioral, dental health and other social needs. The Comprehensive Care Plan must have the following characteristics: • Be member-centric, incorporating the member’s short and long-term health and well-being goals. • Incorporate health literacy and cultural competency attributes based on the individual member needs. • Reflect understanding between the member and the care management team or WICT. • Identify all formal and informal supports, by name or position, that are instrumental to the member’s care plan goals (e.g. family, friends, caregivers, providers, community agencies). Include their role in executing the care plan, and if/how they will receive care plan updates. • Identify the member’s current medical and non- medical needs to be addressed by the care management team or WICT including: o Chronic conditions and acute illnesses; o Mental and behavioral health conditions and history of abuse, violence, or traumatic life events; o Dental care needs; o Medications taken by the member; o Additional supports to conduct activities of daily living (including but not limited to bathing, dressing, and eating) and instrumental activities of daily living (including but not limited to medication management, money management, and transportation); o Social determinants of health; o Other factors that will impact the member’s ability to achieve goals. • Identify and address any gaps in care ensuring that the member has a primary care provider, and behavioral health specialist, dentist, or other health specialists as needed.
