C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.06

Current through 2024-51, December 18, 2024

Subsection 144-101-II-91.06 - COMMUNITY CARE TEAM COVERED SERVICES

91.06-1Comprehensive Care Management

The CCT willcoordinate and provide access to culturally and linguistically appropriate comprehensive care management, care coordination, and transitional care across settings for eligible Members. Levels of care management may change according to Member needs over time.

The CCT shall develop a Plan of Care with each Member served. The Plan of Care shall be recorded in the Member's record and in the CCT's EHR and include the Member's health goals and the services and supports necessary to achieve those goals (including prevention, wellness, specialty care, behavioral health, transitional care and coordination, and social and community services as needed). The CCT shall be responsible for the management, oversight, and implementation of the Plan of Care, including ensuring active Member participation and that measurable progress is made on the plan's goals. Services shall also include:

1. A comprehensive biopsychosocial assessment, conducted face-to-face or via telehealth in accordance with Chapter I, Section 4, which includes the following components:

a. Physical health, including oral health;

b. Mental health, including any history of depression or anxiety;

c. Substance use (including at a minimum, Screening Brief Intervention and Referral to Treatment (SBIRT) services);

d. Medications;

e. Allergies;

f. Family history;

g. Social supports;

h. Housing status;

i. Financial status;

j. Nutritional status;

k. Education;

l. Military service, if applicable;

m. Legal issues;

n. Vocational background;

o. Spirituality and religious preferences; and

p. Leisure and recreational activities.

2. Clinical assessments, monitoring, and follow up of clinical and social service needs;

3. Medication review and reconciliation;

4. Communicating and coordinating care with treating providers;

5. Nurse care management (including patient visits prior to hospital discharge, in the primary care practice, in group visits or at home); and

6. Case/panel management (screening, patient identification, scheduling appointments, referrals to care managers and other team members).

91.06-2Care Coordination

The CCT shall provide intensive and comprehensive care coordination services to address the complex needs of CCT patients and/or to help CCT patients overcome barriers to care:

1. Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines;

2. Coordinate and provide access to preventive, health promotion, treatment, and recovery services, including those related to mental health and substance use;

3. Develop a Plan of Care for each Member that coordinates and integrates all clinical and non-clinical health related needs and services, as appropriate;

4. The CCTs' efforts shall be performed in coordination with, and not duplicate services delivered by, the Member's primary care provider.

91.06-3Health Promotion

The CCT shall promote Member education and chronic illness self-management for Members, in accordance with the United States Preventative Services Task Force recommendations and other evidence-based guidelines for primary, secondary, and tertiary prevention of developing or mitigating the condition(s). This may include, but is not limited to, periodic screening and treatment of tobacco and substance use, diabetes, heart disease, obesity, arthritis, HIV, and depression. Health promotion may also include education on preventing injuries and acute traumatic events, such as interpersonal violence and abuse; the appropriate use and storage of medications; prevention of sexually transmitted infections; regular use of seat belts, car seats, and motorcycle and bicycle helmets; gun and weapon safety measures; functional smoke and carbon monoxide alarms; benefits of consistent exercise and sleep; and other strategies to support a Members' quality of life and wellbeing. Health Promotion shall include identification of risk factors based with targeted follow-up education with the Member, family, and other caregivers and referrals to community-based prevention programs and resources as indicated with periodic updates to ensure ongoing follow-up. The CCT will support continuity of care through coordination with the Member's primary care provider. The CCT will promote evidence-based care, recovery resources, and other services based on individual needs and preferences.

91.06-4Comprehensive Transitional Care

The CCT shall provide Comprehensive Transitional Care to prevent avoidable readmission after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, or treatment facility), reduce avoidable morbidity and mortality related to uncoordinated transitions of care, ensure safe transitions upon release of incarceration, and ensure proper and timely follow-up care from primary care, behavioral health, and/or specialty providers. This service includes:

1. Ensuring that medication reconciliation is completed after transitions of care and conducting a home visit if indicated;

2. Ensuring that timely follow-up visits with all appropriate behavioral and physical health providers are scheduled. The CCT is expected to follow-up to confirm follow-up appointments occurred and help address barriers such as transportation needs to ensure that the visit occurs;

3. Assessing and responding to social service needs identified through discharge planning and follow-up, such as access to food and housing; and

4. Providing care transition support to a lower level of care when the member no longer meets CCT eligibility requirements and is discharged from the CCT panel.

91.06-5Individual and Family Support Services

The CCT shall employ approaches to increase Member and caregiver knowledge about an individual's chronic illness(es), promote the Member's engagement and self-management capabilities, and help the Member improve adherence to their prescribed treatment and Plan of Care. Individual and Family Support Services shall include, but not be limited to:

1. Health coaching for nutrition, physical activity, tobacco cessation, diabetes, asthma, and other chronic diseases;

2. Chronic disease self-management, education, and skill-building;

3. Connection to community-based organizations;

4. Connection to peer support staff, CHWs, support groups, and self-care programs; and

5. Discussing advance directives with Members and their families, guardian(s), or caregivers, as appropriate.

91.06-6Referral to Community and Social Support Services

The CCT shall provide and follow-up on referrals for Members to community, social support, and recovery services. The CCT shall connect Members to community and social service organizations that offer supports for self-management, healthy living, and basic social service needs such as transportation assistance, housing, literacy, economic, and other assistance.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.06