Common use of Care Plan Development Clause in Contracts

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or other appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. In the case of wards, xxxxxx children and former xxxxxx children, the Contractor will also collaborate with Indiana DCS, stakeholders such as community-based service providers, the judicial system, advocates, physical and behavioral health providers, caregivers (including adoptive family or biological family as appropriate) and schools through Individual Education Plans (IEP), in the development of the care plan. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum:  Clinical history;  Diagnosis(es);  Functional and/or cognitive status;  Immediate service needs;  Use of services not covered by the program;  Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services;  Barriers to care (i.e. language, transportation, etc.);  PMP, if applicable;  Care/case manager from a service delivery system, for members with one;  Psychosocial support resources;  Local community resources;  Family member/caregiver/facilitator resources and contact information;  Behavioral health status;  Intensity of services;  Assigned case coordinator for disease management, care management, complex case management, or RCP;  Member self-management goals;  Clearly identified, member-centered, and measurable long-term goals and objectives;  Clearly identified, member-centered, and measurable short-term goals and objectives;  Key milestones towards meeting short-term and long-term goals and objectives;  Planned interventions and contacts with member, providers and/or service delivery system;  Assessment of progress, including input from family, if appropriate; and  Resources to support xxxxxx parents with healthcare coordination, as applicable. The Contractor will have standard protocols in place to assess, plan, implement, re-assess and evaluate members, minimally including:  Pain;  Trouble sleeping;  Anxiety / depression;  Medications – poly-pharmacy and gaps in prescription refills;  Skin;  Bowel / bladder;  Transitions;  Health Maintenance – preventive care;  Health Maintenance – chronic disease management;  Mobility;  Nutrition;  Advance care planning;  Caregiver burden;  Oral health;  Avoiding unwanted pregnancy;  Preventing choking from inappropriate supervision with eating;  Appropriate gait evaluation and adaptive equipment use to prevent fractures;  Assisting wards and xxxxxx children with healthcare coordination during transitions including, but not limited to, placement changes and aging out of xxxxxx care; and  Adjustment to new placement and relationships, in the case of wards and xxxxxx children. When developing the care plan, in addition to working with a multidisciplinary team of qualified health care professionals, the Contractor must ensure that there is a mechanism for members, their families (including biological, xxxxxx, or adoptive, as appropriate), DCS and/or advocates, or others chosen by the member to be actively involved in the care plan development. The Contractor will provide necessary information and support to allow the individual to participate and to actively engage in the process. The care plan must reflect cultural considerations of the member. In addition, the care plan development process must be conducted in plain language, and be accessible to the disabled and limited English proficient. The Contractor must ensure that the care management plan is provided to the member’s PMP (if applicable) or other significant providers. The Contractor must also provide the member the opportunity to review the care plan as requested. Services called for in the care plan will be coordinated by the Contractor’s care coordination staff, in consultation with any other care managers already assigned to a member by another entity (i.e. CMHC, county, provider, DCS or a treatment facility). The Contractor’s care managers for Complex Case Management and RCP must be licensed physician assistants, registered nurses, therapists or social workers and have training, expertise and experience in providing case management and care coordination services for individuals with complex health needs, including individuals with behavioral health needs, developmental disabilities, and who are wards or xxxxxx children. The Contractor’s care managers will work in partnership with a member’s providers and other caregivers to ensure that the members’ overall care is coordinated and well managed. Each member will have an assigned care manager, and each of the Contractor’s care managers may be assigned to multiple members. However, for Complex Case Management and RCP, the member to coordinator ratio will not exceed 50:1, unless otherwise approved in writing by the State. Care plans will delineate a variety of “low touch” and “high touch” interventions and approaches ranging from member educational mailings, telephone contacts with members and providers, face-to-face visits, in-home visits, and telephonic outreach. Interventions may range from passive mailings for preventive care reminders to home visits by the care manager. Respondents shall submit a proposed care plan and indicate which interventions and approaches would be used. Sample care plan(s) should be submitted with the RFP response in substantially the same form as would be provided to the member’s primary provider(s). Respondents should also describe successful interventions and approaches used to gain maximum benefit for each care coordination stratification level. Care plans shall be generally developed in accordance with the member’s current level of service stratification level, as detailed below.

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process. All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or other another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. In the case of wards, xxxxxx children and former xxxxxx children, the Contractor will also collaborate with Indiana DCS, stakeholders such as community-based service providers, the judicial system, advocates, physical and behavioral health providers, caregivers (including adoptive family or biological family as appropriate) and schools through Individual Education Plans (IEP), in the development of the care plan. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely t imely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum:  • Clinical history and pertinent family history;  • Diagnosis(es);  • Functional and/or cognitive status;  Immediate service needs;  Use of services not covered by the program;  Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services;  Barriers to care (i.e. language, transportation, etc.);  PMP, if applicable;  Care/case manager from a service delivery system, for members with one;  Psychosocial support resources;  Local community resources;  Family member/caregiver/facilitator resources and contact information;  Behavioral health status;  Intensity of services;  Assigned case coordinator for disease management, care management, complex case management, or RCP;  Member self-management goals;  Clearly identified, member-centered, and measurable long-term goals and objectives;  Clearly identified, member-centered, and measurable short-term goals and objectives;  Key milestones towards meeting short-term and long-term goals and objectives;  Planned interventions and contacts with member, providers and/or service delivery system;  Assessment of progress, including input from family, if appropriate; and  Resources to support xxxxxx parents with healthcare coordination, as applicable. The Contractor will have standard protocols in place to assess, plan, implement, re-assess and evaluate members, minimally including:  Pain;  Trouble sleeping;  Anxiety / depression;  Medications – poly-pharmacy and gaps in prescription refills;  Skin;  Bowel / bladder;  Transitions;  Health Maintenance – preventive care;  Health Maintenance – chronic disease management;  Mobility;  Nutrition;  Advance care planning;  Caregiver burden;  Oral health;  Avoiding unwanted pregnancy;  Preventing choking from inappropriate supervision with eating;  Appropriate gait evaluation and adaptive equipment use to prevent fractures;  Assisting wards and xxxxxx children with healthcare coordination during transitions including, but not limited to, placement changes and aging out of xxxxxx care; and  Adjustment to new placement and relationships, in the case of wards and xxxxxx children. When developing the care plan, in addition to working with a multidisciplinary team of qualified health care professionals, the Contractor must ensure that there is a mechanism for members, their families (including biological, xxxxxx, or adoptive, as appropriate), DCS and/or advocates, or others chosen by the member to be actively involved in the care plan development. The Contractor will provide necessary information and support to allow the individual to participate and to actively engage in the process. The care plan must reflect cultural considerations of the member. In addition, the care plan development process must be conducted in plain language, and be accessible to the disabled and limited English proficient. The Contractor must ensure that the care management plan is provided to the member’s PMP (if applicable) or other significant providers. The Contractor must also provide the member the opportunity to review the care plan as requested. Services called for in the care plan will be coordinated by the Contractor’s care coordination staff, in consultation with any other care managers already assigned to a member by another entity (i.e. CMHC, county, provider, DCS or a treatment facility). The Contractor’s care managers for Complex Case Management and RCP must be licensed physician assistants, registered nurses, therapists or social workers and have training, expertise and experience in providing case management and care coordination services for individuals with complex health needs, including individuals with behavioral health needs, developmental disabilities, and who are wards or xxxxxx children. The Contractor’s care managers will work in partnership with a member’s providers and other caregivers to ensure that the members’ overall care is coordinated and well managed. Each member will have an assigned care manager, and each of the Contractor’s care managers may be assigned to multiple members. However, for Complex Case Management and RCP, the member to coordinator ratio will not exceed 50:1, unless otherwise approved in writing by the State. Care plans will delineate a variety of “low touch” and “high touch” interventions and approaches ranging from member educational mailings, telephone contacts with members and providers, face-to-face visits, in-home visits, and telephonic outreach. Interventions may range from passive mailings for preventive care reminders to home visits by the care manager. Respondents shall submit a proposed care plan and indicate which interventions and approaches would be used. Sample care plan(s) should be submitted with the RFP response in substantially the same form as would be provided to the member’s primary provider(s). Respondents should also describe successful interventions and approaches used to gain maximum benefit for each care coordination stratification level. Care plans shall be generally developed in accordance with the member’s current level of service stratification level, as detailed below.;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or other appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. In the case of wards, xxxxxx children and former xxxxxx children, the Contractor will also collaborate with Indiana DCS, stakeholders such as community-based service providers, the judicial system, advocates, physical and behavioral health providers, caregivers (including adoptive family or biological family as appropriate) and schools through Individual Education Plans (IEP), in the development of the care plan. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum:  Clinical history;  Diagnosis(es);  Functional and/or cognitive status;  Immediate service needs;  Use of services not covered by the program;  Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services;  Barriers to care (i.e. language, transportation, etc.);  PMP, if applicable;  Care/case manager from a service delivery system, for members with one;  Psychosocial support resources;  Local community resources;  Family member/caregiver/facilitator resources and contact information;  Behavioral health status;  Intensity of services;  Assigned case coordinator for disease management, care management, complex case management, or RCP;  Member self-management goals;  Clearly identified, member-centered, and measurable long-term goals and objectives;  Clearly identified, member-centered, and measurable short-term goals and objectives;  Key milestones towards meeting short-term and long-term goals and objectives;  Planned interventions and contacts with member, providers and/or service delivery system;  Assessment of progress, including input from family, if appropriate; and  Resources to support xxxxxx parents with healthcare coordination, as applicable. The Contractor will have standard protocols in place to assess, plan, implement, re-assess and evaluate members, minimally including:  Pain;  Trouble sleeping;  Anxiety / depression;  Medications – poly-pharmacy and gaps in prescription refills;  Skin;  Bowel / bladder;  Transitions;  Health Maintenance – preventive care;  Health Maintenance – chronic disease management;  Mobility;  Nutrition;  Advance care planning;  Caregiver burden;  Oral health;  Avoiding unwanted pregnancy;  Preventing choking from inappropriate supervision with eating;  Appropriate gait evaluation and adaptive equipment use to prevent fractures;  Assisting wards and xxxxxx children with healthcare coordination during transitions including, but not limited to, placement changes and aging out of xxxxxx care; and  Adjustment to new placement and relationships, in the case of wards and xxxxxx children. When developing the care plan, in addition to working with a multidisciplinary team of qualified health care professionals, the Contractor must ensure that there is a mechanism for members, their families (including biological, xxxxxx, or adoptive, as appropriate), DCS and/or advocates, or others chosen by the member to be actively involved in the care plan development. The Contractor will provide necessary information and support to allow the individual to participate and to actively engage in the process. The care plan must reflect cultural considerations of the member. In addition, the care plan development process must be conducted in plain language, and be accessible to the disabled and limited English proficient. The Contractor must ensure that the care management plan is provided to the member’s PMP (if applicable) or other significant providers. The Contractor must also provide the member the opportunity to review the care plan as requested. Services called for in the care plan will be coordinated by the Contractor’s care coordination staff, in consultation with any other care managers already assigned to a member by another entity (i.e. CMHC, county, provider, DCS or a treatment facility). The Contractor’s care managers for Complex Case Management and RCP must be licensed physician assistants, registered nurses, therapists or social workers and have training, expertise and experience in providing case management and care coordination services for individuals with complex health needs, including individuals with behavioral health needs, developmental disabilities, and who are wards or xxxxxx children. The Contractor’s care managers will work in partnership with a member’s providers and other caregivers to ensure that the members’ overall care is coordinated and well managed. Each member will have an assigned care manager, and each of the Contractor’s care managers may be assigned to multiple members. However, for Complex Case Management and RCP, the member to coordinator ratio will not exceed 50:1, unless otherwise approved in writing by the State. Care plans will delineate a variety of “low touch” and “high touch” interventions and approaches ranging from member educational mailings, telephone contacts with members and providers, face-to-face visits, in-home visits, and telephonic outreach. Interventions may range from passive mailings for preventive care reminders to home visits by the care manager. Respondents shall submit a proposed care plan and indicate which interventions and approaches would be used. Sample care plan(s) should be submitted with the RFP response in substantially the same form as would be provided to the member’s primary provider(s). Respondents should also describe successful interventions and approaches used to gain maximum benefit for each care coordination stratification level. Care plans shall be generally developed in accordance with the member’s current level of service stratification level, as detailed below.;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process. All identified pregnant women who agree to either care management or complex case management shall have a care plan developed in conjunction with the Contractor. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, clinical data from health information exchanges, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or other another appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. In the case of wards, xxxxxx children and former xxxxxx children, the Contractor will also collaborate with Indiana DCS, stakeholders such as community-based service providers, the judicial system, advocates, physical and behavioral health providers, caregivers (including adoptive family or biological family as appropriate) and schools through Individual Education Plans (IEP), in the development of the care plan. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum:  • Clinical history and pertinent family history;  • Diagnosis(es);  • Functional and/or cognitive status;  • Medical Equipment and Medical Equipment Suppliers; • Immediate service needs;  Use of services not covered by the program;  Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services;  Barriers to care (i.e. language, transportation, etc.);  PMP, if applicable;  Care/case manager from a service delivery system, for members with one;  Psychosocial support resources;  Local community resources;  Family member/caregiver/facilitator resources and contact information;  Behavioral health status;  Intensity of services;  Assigned case coordinator for disease management, care management, complex case management, or RCP;  Member self-management goals;  Clearly identified, member-centered, and measurable long-term goals and objectives;  Clearly identified, member-centered, and measurable short-term goals and objectives;  Key milestones towards meeting short-term and long-term goals and objectives;  Planned interventions and contacts with member, providers and/or service delivery system;  Assessment of progress, including input from family, if appropriate; and  Resources to support xxxxxx parents with healthcare coordination, as applicable. The Contractor will have standard protocols in place to assess, plan, implement, re-assess and evaluate members, minimally including:  Pain;  Trouble sleeping;  Anxiety / depression;  Medications – poly-pharmacy and gaps in prescription refills;  Skin;  Bowel / bladder;  Transitions;  Health Maintenance – preventive care;  Health Maintenance – chronic disease management;  Mobility;  Nutrition;  Advance care planning;  Caregiver burden;  Oral health;  Avoiding unwanted pregnancy;  Preventing choking from inappropriate supervision with eating;  Appropriate gait evaluation and adaptive equipment use to prevent fractures;  Assisting wards and xxxxxx children with healthcare coordination during transitions including, but not limited to, placement changes and aging out of xxxxxx care; and  Adjustment to new placement and relationships, in the case of wards and xxxxxx children. When developing the care plan, in addition to working with a multidisciplinary team of qualified health care professionals, the Contractor must ensure that there is a mechanism for members, their families (including biological, xxxxxx, or adoptive, as appropriate), DCS and/or advocates, or others chosen by the member to be actively involved in the care plan development. The Contractor will provide necessary information and support to allow the individual to participate and to actively engage in the process. The care plan must reflect cultural considerations of the member. In addition, the care plan development process must be conducted in plain language, and be accessible to the disabled and limited English proficient. The Contractor must ensure that the care management plan is provided to the member’s PMP (if applicable) or other significant providers. The Contractor must also provide the member the opportunity to review the care plan as requested. Services called for in the care plan will be coordinated by the Contractor’s care coordination staff, in consultation with any other care managers already assigned to a member by another entity (i.e. CMHC, county, provider, DCS or a treatment facility). The Contractor’s care managers for Complex Case Management and RCP must be licensed physician assistants, registered nurses, therapists or social workers and have training, expertise and experience in providing case management and care coordination services for individuals with complex health needs, including individuals with behavioral health needs, developmental disabilities, and who are wards or xxxxxx children. The Contractor’s care managers will work in partnership with a member’s providers and other caregivers to ensure that the members’ overall care is coordinated and well managed. Each member will have an assigned care manager, and each of the Contractor’s care managers may be assigned to multiple members. However, for Complex Case Management and RCP, the member to coordinator ratio will not exceed 50:1, unless otherwise approved in writing by the State. Care plans will delineate a variety of “low touch” and “high touch” interventions and approaches ranging from member educational mailings, telephone contacts with members and providers, face-to-face visits, in-home visits, and telephonic outreach. Interventions may range from passive mailings for preventive care reminders to home visits by the care manager. Respondents shall submit a proposed care plan and indicate which interventions and approaches would be used. Sample care plan(s) should be submitted with the RFP response in substantially the same form as would be provided to the member’s primary provider(s). Respondents should also describe successful interventions and approaches used to gain maximum benefit for each care coordination stratification level. Care plans shall be generally developed in accordance with the member’s current level of service stratification level, as detailed below.;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or other appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. In the case of wards, xxxxxx children and former xxxxxx children, the Contractor will also collaborate with Indiana DCS, stakeholders such as community-based service providers, the judicial system, advocates, physical and behavioral health providers, caregivers (including adoptive family or biological family as appropriate) and schools through Individual Education Plans (IEP), in the development of the care plan. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum:  • Clinical history;  • Diagnosis(es);  • Functional and/or cognitive status;  • Immediate service needs;  • Use of services not covered by the program;  • Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services;  • Barriers to care (i.e. language, transportation, etc.);  • PMP, if applicable;  • Care/case manager from a service delivery system, for members with one;  • Psychosocial support resources;  • Local community resources;  • Family member/caregiver/facilitator resources and contact information;  • Behavioral health status;  • Intensity of services;  • Assigned case coordinator for disease management, care management, complex case management, or RCP;  • Member self-management goals;  • Clearly identified, member-centered, and measurable long-term goals and objectives;  • Clearly identified, member-centered, and measurable short-term goals and objectives;  • Key milestones towards meeting short-term and long-term goals and objectives;  • Planned interventions and contacts with member, providers and/or service delivery system;  • Assessment of progress, including input from family, if appropriate; and  • Resources to support xxxxxx parents with healthcare coordination, as applicable. The Contractor will have standard protocols in place to assess, plan, implement, re-assess and evaluate members, minimally including:  • Pain;  • Trouble sleeping;  • Anxiety / depression;  • Medications – poly-pharmacy and gaps in prescription refills;  • Skin;  • Bowel / bladder;  • Transitions;  • Health Maintenance – preventive care;  • Health Maintenance – chronic disease management;  • Mobility;  Nutrition;  Advance care planning;  Caregiver burden;  Oral health;  Avoiding unwanted pregnancy;  Preventing choking from inappropriate supervision with eating;  Appropriate gait evaluation and adaptive equipment use to prevent fractures;  Assisting wards and xxxxxx children with healthcare coordination during transitions including, but not limited to, placement changes and aging out of xxxxxx care; and  Adjustment to new placement and relationships, in the case of wards and xxxxxx children. When developing the care plan, in addition to working with a multidisciplinary team of qualified health care professionals, the Contractor must ensure that there is a mechanism for members, their families (including biological, xxxxxx, or adoptive, as appropriate), DCS and/or advocates, or others chosen by the member to be actively involved in the care plan development. The Contractor will provide necessary information and support to allow the individual to participate and to actively engage in the process. The care plan must reflect cultural considerations of the member. In addition, the care plan development process must be conducted in plain language, and be accessible to the disabled and limited English proficient. The Contractor must ensure that the care management plan is provided to the member’s PMP (if applicable) or other significant providers. The Contractor must also provide the member the opportunity to review the care plan as requested. Services called for in the care plan will be coordinated by the Contractor’s care coordination staff, in consultation with any other care managers already assigned to a member by another entity (i.e. CMHC, county, provider, DCS or a treatment facility). The Contractor’s care managers for Complex Case Management and RCP must be licensed physician assistants, registered nurses, therapists or social workers and have training, expertise and experience in providing case management and care coordination services for individuals with complex health needs, including individuals with behavioral health needs, developmental disabilities, and who are wards or xxxxxx children. The Contractor’s care managers will work in partnership with a member’s providers and other caregivers to ensure that the members’ overall care is coordinated and well managed. Each member will have an assigned care manager, and each of the Contractor’s care managers may be assigned to multiple members. However, for Complex Case Management and RCP, the member to coordinator ratio will not exceed 50:1, unless otherwise approved in writing by the State. Care plans will delineate a variety of “low touch” and “high touch” interventions and approaches ranging from member educational mailings, telephone contacts with members and providers, face-to-face visits, in-home visits, and telephonic outreach. Interventions may range from passive mailings for preventive care reminders to home visits by the care manager. Respondents shall submit a proposed care plan and indicate which interventions and approaches would be used. Sample care plan(s) should be submitted with the RFP response in substantially the same form as would be provided to the member’s primary provider(s). Respondents should also describe successful interventions and approaches used to gain maximum benefit for each care coordination stratification level. Care plans shall be generally developed in accordance with the member’s current level of service stratification level, as detailed below.;

Care Plan Development. After the initial assessment and stratification, the Contractor shall assign members to a care level, develop a care plan for each member, and facilitate and coordinate the holistic care of each member according to his or her needs. The Contractor shall utilize a person-centered care plan development planning process. The Contractor will use data from multiple sources in the development of each member’s care plan, including, at minimum, claims data, data collected during the initial screening, the follow-up comprehensive health assessment, available medical records, Indiana Scheduled Prescription Electronic Collection & Tracking (INSPECT) and any other sources, to ensure that the care for members is adequately coordinated and appropriately managed. Through data analysis and predictive modeling, the Contractor will identify members who are at the highest risk for hospitalization or relapse, or high cost and/or high utilization in the future. In addition, the Contractor will gather information about the level and type of existing care and/or case management services that the member may already be receiving, for example, through a CMHC. The Contractor will use the information to identify gaps in the member’s current treatment approach, and communicate those findings to the member’s PMP (if applicable) or other appropriate physician. The Contractor will assist the member, the member’s family and the member’s physician(s) to develop a care plan with specific objectives, goals and action protocols to meet identified needs. In the case of wards, xxxxxx children and former xxxxxx children, the Contractor will also collaborate with Indiana DCS, stakeholders such as community-based service providers, the judicial system, advocates, physical and behavioral health providers, caregivers (including adoptive family or biological family as appropriate) and schools through Individual Education Plans (IEP), in the development of the care plan. The Contractor will initiate and facilitate specific activities, interventions and protocols that lead to accomplishing the goals set forth in the care plan, and shall be responsible for EXHIBIT 1.M SCOPE OF WORK developing strategies to facilitate timely and secure communication and information sharing between providers, caregivers, and stakeholders. The care plan will include, at a minimum:  Clinical history;  Diagnosis(es);  Functional and/or cognitive status;  Immediate service needs;  Use of services not covered by the program;  Accommodation needs (e.g., special appointment times, alternative formats) and auxiliary aids and services;  Barriers to care (i.e. language, transportation, etc.);  PMP, if applicable;  Care/case manager from a service delivery system, for members with one;  Psychosocial support resources;  Local community resources;  Family member/caregiver/facilitator resources and contact information;  Behavioral health status;  Intensity of services;  Assigned case coordinator for disease management, care management, complex case management, or RCP;  Member self-management goals;  Clearly identified, member-centered, and measurable long-term goals and objectives;  Clearly identified, member-centered, and measurable short-term goals and objectives;  Key milestones towards meeting short-term and long-term goals and objectives;  Planned interventions and contacts with member, providers and/or service delivery system;  Assessment of progress, including input from family, if appropriate; and  Resources to support xxxxxx parents with healthcare coordination, as applicable. The Contractor will have standard protocols in place to assess, plan, implement, re-assess and evaluate members, minimally including: EXHIBIT 1.M SCOPE OF WORK  Pain;  Trouble sleeping;  Anxiety / depression;  Medications – poly-pharmacy and gaps in prescription refills;  Skin;  Bowel / bladder;  Transitions;  Health Maintenance – preventive care;  Health Maintenance – chronic disease management;  Mobility;  Nutrition;  Advance care planning;  Caregiver burden;  Oral health;  Avoiding unwanted pregnancy;  Preventing choking from inappropriate supervision with eating;  Appropriate gait evaluation and adaptive equipment use to prevent fractures;  Assisting wards and xxxxxx children with healthcare coordination during transitions including, but not limited to, placement changes and aging out of xxxxxx care; and  Adjustment to new placement and relationships, in the case of wards and xxxxxx children. When developing the care plan, in addition to working with a multidisciplinary team of qualified health care professionals, the Contractor must ensure that there is a mechanism for members, their families (including biological, xxxxxx, or adoptive, as appropriate), DCS and/or advocates, or others chosen by the member to be actively involved in the care plan development. The Contractor will provide necessary information and support to allow the individual to participate and to actively engage in the process. The care plan must reflect cultural considerations of the member. In addition, the care plan development process must be conducted in plain language, and be accessible to the disabled and limited English proficient. The Contractor must ensure that the care management plan is provided to the member’s PMP (if applicable) or other significant providers. The Contractor must also provide the member the opportunity to review the care plan as requested. Services called for in the care plan will be coordinated by the Contractor’s care coordination staff, in consultation with any other care managers already assigned to a member by another entity (i.e. CMHC, county, provider, DCS or a treatment facility). The Contractor’s care managers for Complex Case Management and RCP must be licensed physician assistants, EXHIBIT 1.M SCOPE OF WORK registered nurses, therapists or social workers and have training, expertise and experience in providing case management and care coordination services for individuals with complex health needs, including individuals with behavioral health needs, developmental disabilities, and who are wards or xxxxxx children. The Contractor’s care managers will work in partnership with a member’s providers and other caregivers to ensure that the members’ overall care is coordinated and well managed. Each member will have an assigned care manager, and each of the Contractor’s care managers may be assigned to multiple members. However, for Complex Case Management and RCP, the member to coordinator ratio will not exceed 50:1, unless otherwise approved in writing by the State. Care plans will delineate a variety of “low touch” and “high touch” interventions and approaches ranging from member educational mailings, telephone contacts with members and providers, face-to-face visits, in-home visits, and telephonic outreach. Interventions may range from passive mailings for preventive care reminders to home visits by the care manager. Respondents shall submit a proposed care plan and indicate which interventions and approaches would be used. Sample care plan(s) should be submitted with the RFP response in substantially the same form as would be provided to the member’s primary provider(s). Respondents should also describe successful interventions and approaches used to gain maximum benefit for each care coordination stratification level. Care plans shall be generally developed in accordance with the member’s current level of service stratification level, as detailed below.