MOC Communication & ICT September 5, 2014 Training for PPGs
Learning Objective After this training you will understand the roles of the Interdisciplinary Care Team (ICT) in the SNP & Cal MediConnect Model of Care, as well as the importance of communication to support our members needs
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About The Interdisciplinary Care Team What is an ICT? Who will have an ICT? Where does the ICT reside? What does the ICT do? When do they meet?
What Is An ICT? An ICT is a collaborative, multidisciplinary team who: Analyzes and incorporates the results of the initial and annual health risk assessment into the care plan. Develops a collaborative Individualized Care plan (ICP) and annually update the member s ICP. Manages the medical, cognitive, psychosocial and functional needs of each member. Communicates the ICP to all caregivers for care coordination. Coordinates with and facilitates referrals to the appropriate resources, medical, behavioral health or home and community based providers, i.e. LTSS
Who Is On The ICT? Composed of contracted and employed staff who are knowledgeable, licensed, and (as appropriate) credentialed individuals involved or closely associated with the care of the member. Selected based on population needs, such as Clinicians experienced in managing geriatric and/or chronically ill populations Support providers serving vulnerable disadvantaged populations Licensed behavioral health practitioners Staff with expertise in Medicare and Medicaid operations NOTE: ICTs can be specific to LTSS and Behavioral Health services
Who Is On The ICT? The member is at the center of the care planning process and may choose to include clinical or non-clinical staff and/family or caregivers. The member may also choose to exclude participants as part of their right to self-direct care. Possible ICT members include: Member/Caregiver/Auth.Rep. Designated PCP and/or Specialist Nurse Care Manager Social Worker Patient Navigator County IHSS Social Worker IHSS Provider with approval from member Pharmacist Behavioral Health provider(s) Other professional staff in provider network MSSP Coordinator
Who Leads An ICT? The Care Manager (licensed staff member) is the Team Leader, responsible for organizing the ICT in response to: Member or provider requests Negative events or needs identified via the Health Risk Assessment (HRA) Other previous assessments such as medical, LTSS (IHSS, CBAS, MSSP), nursing facility and Behavioral Health assessments
Who Will Have an ICT? Who Will Have an ICT? All Members will have an ICT Low risk members will have an ICT comprised of the PCP and support staff at the PPG Moderate risk members will have an ICT lead by PPG CM High Risk Members will have the most developed ICTs with more interaction with the member than lower risk stratified members.
ICT Meetings ICT Meetings are avenue to: Discuss complex needs Identify linkages to home and community-based services Follow-up on utilization, level of care or other specialized services Track types and numbers of referral made Communicate with all stakeholders
Communication Details Modes -Telephonic -In person -Fax/email documents Member-Centered Preferences -Language -Literacy -Cultural -Disabilities -Vision/Hearing 12
When Does The ICT Meet? Meet initially to develop the ICP and at least annually thereafter When there is a change in the member s conditions (trigger) At the request of the member
ICT Communication Care Coordination/Care Management includes scheduled and ad hoc care coordination / case management rounds and meetings with written minutes; sharing of the ICP across all ICT membership Sharing ICT meeting notes/minutes as requested maintained in a HIPAA compliant format within L.A. Care s information Systems for 10 years from the meeting date.
ICT Responsibilities Analyze and incorporate initial and annual HRA results into an Individualized Care plan (ICP) Collaborate on development and annual update of each member s care plan Communicate coordinated care plans across all settings Manage the member s medical /cognitive / psychosocial / functional needs and communicate to the member, caregiver (as appropriate, and PCP Assess and address identified social service barriers to achieving ICP goals Assess members for access to long-term care services and supports enabling them to remain in their homes and communities as long as possible Coordinate ICP integration addressing Medical and social needs Engage members to self-direct their care Provide and support person-centered care coordination and planning Identify community-based resources as needed and make referrals Assist with measuring effectiveness and extent to which care is managed
ICT Timing Care managers must develop an initial ICP within 30 days of the initial health risk assessment completion ICPs are discussed with the ICT within 14 days of completion. Meeting minutes document PCP/member/caregiver participation. External participants will be given assigned call-in times to ensure confidentiality. Signed confidentiality agreements will maintain HIPAA compliance. ICT recommendations and ICPs are available upon request by the member, the member s legal representative, the PCP or pertinent providers. The ICT report will be mailed within 14 calendar days of the request.
ICT & Communication: Supporting Reference CMS Manual: Chapter 16b Code of Federal Regulations L.A. Care ICT P&P #406 SNP Model of Care CMC Model of Care 17