M-C/CM 1: Care Management Process (QI7/Element A) The Care Management Program and/or policy and procedure must include a written description of the process to coordinate services and help Members access needed resources (Provider Manual 12A.2):.5 1 NA Refer comple cases to IEHP 2 The IPA P&P must include process to refer comple cases to IEHP. 3 Coordinate care with the PCP and/or Specialist Requirement Met #DIV/! Element B: Staff Responsibilities There must be a description that defines the roles and responsibilities for (Provider Manual 12A.1, 2): 1 Care Managers (licensed RN / LVN). 2 Practitioners / IPA Medical Director. 3 Ancillary Personnel (Nutritionist, Social Worker, etc.) (May be n/a if IPA does not employee ancillary staff for CM)..5 1 NA Requirement Met Element C: Evidence of Care Management Process (FILE REVIEW) 1 Care Management file review must demonstrate the care management process, including use of Evidenced-based guidelines (e.g. CMSA guidelines). Random pull of 1 Care Management files 1% - 9% = full score of 1 89% - 8% = score of.5 Less then 79% = score of (see file review Work Sheet for details).5 1 NA #DIV/! Total Requirements Element C Requirement Met 1 #DIV/! M-C/CM 2: California Children s Services (CCS) The policy and procedure for CCS must include a written description of the process to (Provider Manual 12B):.5 1 NA 1 Identify actual and potential cases. 2 Refer potential cases, appropriately and timely (within 24 hours of identification), to CCS (Provider Manual 12A.2). 3 Coordinate care with the PCP and/or SCP (whether eligible or not). 4 Follow cases through the outpatient treatment process and assist with COC. 5 Continue all medically necessary care within the IPA network when not eligible for CCS. Requirement Met #DIV/! M-C/CM 3: High Risk OB Care (HROB) The IPA has an established policy for identifying, referring and coordinating care for HROB members. The policy must contain the following high risk indicators (Provider Manual 1.D.1): *HROB Members must be referred for evaluation and care if beyond the scope of practice of the initial prenatal practitioner and Referred to IEHP HM department, when indicated: 1 Evidence or history of asthma, gestational diabetes, preeclampsia, or eclampsia. 2 Indication of multiple fetuses. 3 Prior C-Sections. 4 History of complicated deliveries such as placenta previa or abruptio placenta. 5 History of pregnancy difficulties such as incompetent cervi. 6 Prior premature labor and/or delivery. 7 History of substance use or abuse. 8 Homelessness. 9 Under age 18 or over 35 years of age..5 1 NA DOA CM Preliminary Scoring Page 1
Requirement Met Element B: Implementation of HROB Coordination of Care (FILE REVIEW) 1 There is documented evidence that HROB care is coordinated timely. (Provider Manual 12A.2) *The evaluation of this element will be based on review of a random sample of CM files..5 1 NA #DIV/! Requirement Met 1 #DIV/! M-C/CM 4: Sensitive Services There are written policy and procedures describing sensitive services, which must include that members do not require an authorization for self-referring to a provider of their choice for specific sensitive services (Provider Manual see below): In-Network: (Note: Minor = 16 years old and not legally an adult). 1 Seually Transmitted Disease D/T (1H). 2 HIV testing and counseling (1I). 3 Pregnancy / pregnancy testing (9E). 4 Abortions (9E). 5 T for Seual Assault (9E). 6 Drug / Alcohol treatment (12K.2). 7 Mental health care (12K.1). Out-of-Network: 8 Family Planning (1G). 9 Seual assault T (Provider Manual 9E minors of any age)..5 1 NA 1 Rape (Provider Manual 9E minor 12 year or older). 11 Abortion (Provider Manual 9E - minors of any age). 12 Birth Control (Provider Manual 9E minors of any age, ecept sterilization) 13 Drug or alcohol treatment services (Provider Manual 12K.2 - minors 12 years or older for both federally and non-federally assisted T programs). 14 HIV Testing & Counseling (Provider Manual 1I minors 12 years or older and competent). 15 Pregnancy prevention, D, T (Provider Manual 1.D minors of any age). 16 Family planning (Provider Manual 1G) no Auth, any qualified Provider. 17 STD D, T contagious & reportable D (Provider Manual 1H - minors 12 years or older). 18 Outpatient Mental health T (Provider Manual 12K.1 - minors 12 years or older). 19 Communicable D Reporting (Provider Manual 1K). 2 Sterilizations (Provider Manual 1F). Requirement Met #DIV/! M-C/CM 5: Carve-Out / Waiver Programs / Dis-enrollments / Transition of Care The written policy and procedure for cases meeting the criteria must include the process used to (Provider Manual see below): 2 Refer timely. 3 Coordinate care (CM must ensure COC into appropriate program). Disenrollment(s): 5 Long term care (Provider Manual 12F) 6 Major organ transplant (Provider Manual 12G) ecludes kidney and cornea for Medi-Cal. 7 Adult Day Health (Provider Manual 12H) per State, disenroll to FFS. Waiver Programs: {Home & Community Based Services (HCB)}. 8 Department of Developmental Services (Provider Manual 12I.1). 9 Multipurpose Senior Services (MSSP) (Provider Manual 12I.2). 1 AIDS/ARC Waiver (Provider Manual 12I.3). 11 Nursing Facility (Provider Manual 12I.4.a). 12 Model Waiver Program (Provider Manual 12I.4.b). Carve-Out(s): 13 Dental (Provider Manual 12J) incorporate modified benefits (<21 only). 14 Vision (Provider Manual 12M) incorporate modified benefits..5 1 NA Requirement Met #DIV/! DOA CM Preliminary Scoring Page 2
Element B: Implementation (FILE REVIEW) There is evidence of care coordination between the IPA, Member, provider, practitioner, and Health Plan, which must include: *The Carve-Out evaluation / Waiver of this Programs: element will be based on review of a 1 Appropriate and timely referrals for potential cases. 2 Appropriate notification for accepted or denied cases. 3 Documentation information sent to Health Plan. Disenrollment: 4 Identification of potential/actual cases. 5 Initiated disenrollment with the IPA or Health Plan, appropriately. 6 Handled Divorces appropriately (Provider Manual 17A.2)..5 1 NA Transition of Care: 7 Appropriate, timely transition of care for members whose health plan coverage has changed (e.g. no longer with assigned IPA or Health Plan). Requirement Met M-C/CM 6: Community and/or Public Health Services The written description regarding Community and/or Public Health Services must include the process used to:.5 1 NA 2 Refer timely. 3 Coordinate care. The scope of services includes, but is not limited to, the specific agencies funded by the county, state and/or federal funds: 4 Early & Periodic Screening, D, T (EPSDT) (Provider Manual 12D). 5 School-linked Services (Provider Manual 1C.4). 6 Early Start Services and Referrals (Provider Manual 12C). 7 Tuberculosis Services (Provider Manual 1J). 8 Immunizations Services (Provider Manual 1C.3). 9 Developmental Disabilities / Regional Centers (Provider Manual 12N). 1 WIC Program (Provider Manual 1E) 11 Genetically Handicapped Persons (GHPP) (Provider Manual 12E). 12 Reporting Potential Abuse (Provider Manual 12A.5). Community and Public Service Programs Policy #DIV/! Requirement Met Element B: Implementation / Coordination of Care (FILE REVIEW) 1 There is documented evidence that community and public health agencies are made available and utilized by the IPA. The evaluation of this element will be based on review of a random sample of CM files..5 1 NA #DIV/! Requirement Met 1 #### #### N/A DOA CM Preliminary Scoring Page 3
NCQA QI 5: Comple Case Management The organization coordinates services for members with comple conditions and helps them access needed resources. Element B: Program Description The description of the organization s comple case management program includes: 1 Evidence used to develop the program. 2 Criteria for identifying members who are eligible for the program. 3 Services offered to individuals. 4 Defined program goals. 5 How case management services are integrated with the services of others involved in the member s care..5 1 NA Requirement Met #DIV/! Element C: Identifying Members for Case Management The organization uses the following sources to identify members for comple case management: 1 Claims or encounter data. 2 Hospital discharge data. 3 Pharmacy data, if applicable. 4 Data collected through the UM management process, if applicable. 5 Data supplied by purchasers, if applicable. 6 Data supplied by members or caregivers. 7 Data supplied by practitioners..5 1 NA Total Requirements Element C Requirement Met #DIV/! Element D: Access to Case Management The organization has multiple avenues for members to be considered for comple case management services, including: 1 Health information line referral, if applicable. 2 DM program referral. 3 Discharge planner referral. 4 UM referral, if applicable. 5 Member or caregiver referral. 6 Practitioner referral..5 1 NA Total Requirements Element D Requirement Met #DIV/! Element E: Case Management Systems The organization uses case management systems that support: 1 Evidence-based clinical guidelines or algorithms to conduct assessment and management. 2 Automatic documentation of the staff member s ID and date, and time of action on the case or when interaction with the member occurred. 3 Automated prompts for follow-up, as required by the case management plan..5 1 NA Total Requirements Element E Requirement Met #DIV/! DOA CM Preliminary Scoring Page 4
Element F: Case Management Process The organization s comple case management procedures address the following: 1 Initial assessment of members health status, including condition-specific issues. 2 Documentation of clinical history, including medications..5 1 NA 3 Initial assessment of the activities of daily living. 4 Initial assessment of behavioral health status, including cognitive functions. 5 Initial assessment of psychosocial issues. 6 Initial assessment of life-planning activities. 7 Evaluation of cultural and linguistic needs, preferences or limitations. 8 Evaluation of visual and hearing needs, preferences or limitations. 9 Evaluation of caregiver resources and involvement. 1 Evaluation of available benefits. 11 Evaluation of community resources. 12 Development of an individualized case management plan, including prioritized goals, that considers the member s and caregivers goals, preferences and desired level of involvement in the case management plan. 13 Identification of barriers to a member meeting goals or complying with the plan. 14 Facilitation of member referrals to resources and follow-up process to determine whether members act on referrals. 15 Development of a schedule for follow-up and communication with members. 16 Development and communication of member selfmanagement plans. 17 A process to assess members progress against case management plans for members. Total Requirements Element F Requirement Met #DIV/! Element H: Case Management (file review) The NCQA review of a sample of the organization s comple case management files that demonstrates that the organization follows its documented processes for:.5 1 NA 1 Development of case management plans, including prioritized goals, that take into account member and caregivers goals, preferences and desired level of involvement in the comple case management program. 2 Identification of barriers to meeting goals and complying with the plans. 3 Development of schedules for follow-up and communication with members. 4 Development and communication of member selfmanagement plans. 5 Assessment of progress against case management plans and goals, and modification as needed. Total Requirements Element H Requirement Met #DIV/! CM Total : DOA CM Preliminary Scoring Page 5