UCare Connect Care Coordination Requirement Grid Updated 8.1.18 effective 9.1.18 The assigned Care Coordinator (CC) must meet the required definition of a qualified professional. Care coordination services incorporate complex case management and consist of a comprehensive assessment of the member s condition, the determination of available benefits and resources, the development and implementation of an individualized care plan with performance goals, and monitoring and follow-up, as described in the grid below. Community Non-Waiver Members Community Waiver Members Institutionalized Members Initial Assignment Initial Contact with Member Assessment Review and Development of the Plan of Care Upon receiving the enrollment roster, the CC is required to: Look each member up in MN-ITS to determine waiver status. Return members to UCare via the Monthly Activity Log if MN-ITS indicates the member is open to a waiver, TCM, or the member is institutionalized. **Do not continue care coordination for these members.** Provide the member with the name and phone number of the CC assigned within 10 calendar days of initial assignment. Initial assignment is the first day the delegate organization receives the enrollment roster. Notification may be done by phone or letter and the contact must be documented. If contact is by letter, the CC must use UCare s approved Care Coordinator Welcome Letter found on UCare s website. Contact the member, either Return members to UCare via the Monthly Activity Log if MN-ITS indicates telephonically or face-to-face, the member is open to a waiver. **Do not continue care coordination for these within the month of assignment to members.** review information in the comprehensive assessment. Develop a Person Centered Plan of Care (POC) using the UCare Connect Plan of Care form, or other UCare approved form within 30 days of completion of 8.1.18 1
Initial Contact with Member/ Unable to Reach or Refusal the assessment review. (Delegates may opt to do a faceto-face visit but it is not required). Maintain a record of the assessment and POC in the member s case file. Share the assessment and POC information with UCare upon request. Make a minimum of 4 attempts to contact the member within the month of enrollment. Contacts may be by phone, face-to-face, on different days, and at different times, and/or by using the Unable to Contact Letter on UCare s website. At least 3 of these attempts must be made by phone. A good faith effort should be made to obtain a working phone number for the member. (Sending the Care Coordinator Welcome Letter is not considered an attempt to contact the member). If the CC is unable to contact the member after six consecutive months of attempts, the CC is required to: Add the member to the Monthly Activity Log as a refusal and Return the member to UCare via the Monthly Activity Log if MN-ITS indicates the member is open to a waiver. **Do not continue care coordination on these members.** 8.1.18 2
return to UCare by the 20 th day of the following month. Product Change- this is when a member moves from Connect Regular or Expansion to Connect + Medicare and vice versa. Entry of Assessments on Monthly Activity Log Admission to a Nursing Facility from the Community If there is a change in CC due to a product change, the existing (sending) CC is required to: Send a copy of the current HRA and POC, and relevant case notes to the new (receiving) CC. The new (receiving) CC is required to: Provide the member with the name and telephone number of the new CC within 10 days of the assignment. This may be done by phone or letter (using the approved letter on UCare s website), and must be documented in the case record. Obtain and review the current HRA and POC from the previous (sending) CC. Review the POC and update as necessary. If unable to obtain a completed HRA and POC that was completed within the last 365 days, or if there has been a change in condition, the CC is required to complete a new HRA (DHS-3428H form) and POC face-to-face. Enter the assessment into MMIS. Document all product change assessments on the Monthly Activity Log. Enter all assessments and refusals on the Monthly Activity Log. Submit the Monthly Activity Log to connectintake@ucare.org by the 20 th calendar day of the following month. If a member is admitted to a Nursing Facility and their stay is expected to be less than 90 days, keep the member open to care coordination. If it is expected that the member will be admitted for greater than 90 days, the CC is required to return the member to UCare via the Monthly Activity N/A 8.1.18 3
Comprehensiv e Plan of Care (POC) Log. UCare Responsibilities: Complete all Preadmission Screening and Resident Review (PASRR) activities. Notify the delegate when a PASRR is received. CC Responsibilities: Monitor the daily authorization report for admissions. Assist with transitions and complete a TOC log. Develop and implement a personcentered comprehensive POC within 30 days of the assessment review. This takes into account input from the member and/or family members, the member s authorized health care decision maker, Primary Care Physician (PCP), and other interdisciplinary care team members as applicable. The CC develops the personcentered POC using the Care Plan document found on UCare s website. The POC is based on the information collected through N/A 8.1.18 4
telephonic or face-to-face review of the comprehensive assessment with the member or legal guardian, and includes: o Member problem list/needs. o Discussion of service back-up plan. o Prioritized member goals. o Member driven interventions to address medical, social, behavioral, educational, and other service needs of the member. o Member s strengths and services in place. o Measurable outcomes (must be monitored and POC revised as necessary) with a target achievement date identified by month/year. Fax a copy of the POC or a POC summary to the member s PCP and specialist (as applicable) on an annual basis. Communicate updates and 8.1.18 5
Plan of Care Signature Page Ongoing Contact with Member and Plan of Care Updates changes in the member s condition to the PCC as appropriate. Complete the Personal Risk Management Plan (PRMP) section of the POC when the member refuses services, and document PRMP discussion with the member. Obtain a signature from the member or authorized representative on the POC on an annual basis to document that they have discussed their care plan with their CC. The POC is not considered valid unless signed by the member or authorized representative. Maintain ongoing contact or check-in with the member at a minimum of every 90 days (quarterly) to update the POC which includes documenting the monitoring of progress or goal revisions (with date). Contact may be by phone or face-to-face (refer to contact attempt N/A N/A 8.1.18 6
Reassessment requirements in the unable to reach or refusal section). Return the member to UCare via the Monthly Activity Log if any of the following occur: The CC is unable to reach the member after attempting for six consecutive months. The member opens to a waiver or TCM/ACT services. The member becomes a longterm resident of a skilled nursing facility. Complete a face-to-face HRA using the DHS-3428H-HRA form within 365 days of the previous assessment or upon a change in condition. When completing the HRA, all questions and sections must be completed or marked as not applicable. Enter the DHS-3437H form in MMIS. Enter the reassessment on the Monthly Activity Log and return to UCare by the 20 th of the following month. N/A 8.1.18 7
Medicaid Eligibility Renewals Reassessments When Member is in the 90 Day Grace Period After MA Terminates Advance Directives Update the Date Goal Achieved/Not Achieved column from the previous year s POC with a month and year documented and retain in member s file. Develop a new POC with ongoing and new goals within 30 days of the HRA. Send the POC or POC summary to the PCP and member/rep within 30 calendar days of the HRA date. Review the UCare Connect eligibility renewal report, provided by UCare, on a monthly basis and remind members when they are at risk of losing Medicaid eligibility due to incomplete or unprocessed Medical Assistance paperwork. The UCare Retention Specialist reaches out to members to see if they need additional assistance with maintaining eligibility. If a member s Medical Assistance (MA) terms, the CC is required to discontinue providing care coordination services but monitor the member for up to 90 days. If their annual reassessment is due during the 90 day term window, the CC is required to: Complete the annual reassessment and maintain in the member s file. Enter the DHS-3427H form into MMIS if and when the member s MA is reinstated. o If there is a assessment completed within 365 days of the previous assessment it can be reviewed with the member via telephonically or face-to-face and entered in MMIS. Enter the assessment on the Monthly Activity Log. Document on an annual basis that they addressed or discussed advance directives with the member, or; 8.1.18 8
Document the reason why advance directives were not discussed. Transition of Care (TOC) Coordination with Local Agencies Assist with the member s planned and unplanned movement from one care setting (e.g., member s home, hospital, and skilled nursing facility) to another care setting. Each movement, when due to a change in the member s health status, is considered a separate transition. Conduct Transition of Care activities and document these activities on the Transitions of Care Log on UCare s website, according to the TOC Log instructions.. Conduct a reassessment in the event of a care transition that may involve significant health changes, repeated or multiple falls, recurring hospital readmissions or emergency room visits. If the CC finds out about the transition(s) 15 days or more after the member has returned to their usual care setting, the CC is not required to complete a TOC log, however, the CC is required to: Follow-up with the member to discuss the care transition process, and any changes to their health status and POC. Provide education about how to prevent readmission, and document this discussion in case notes. Refer to the TOC log instructions on the UCare website for additional instruction. The CC is required to make referrals and/or coordinate care with county social services and other community resources when a member is in need of: Pre-petition screening. Home and Community Based Services (HCBS). County case management for HCBS. Child protection. Court ordered treatment. Case management and service providers for people with DD. Mental Health Targeted Case Management (MH-TCM). Behavioral Health Home. Adult protection services. Assessment of medical barriers to employment. Relocation services. 8.1.18 9
DTR Requirements- Medically Necessary Services Transfer of Member Between Delegates Member Death Nursing home, residential, or home care providers. State Medical Review Team or Social Security disability determination. Work with local agency staff or county attorney staff for members who are victims or perpetrators in criminal cases. Assessment and evaluation related to judicial proceedings. Assertive Community Treatment (ACT), Intensive Residential Therapy Services (IRTS), or Adult Rehabilitative Mental Health Services (ARMHS). UCare or one of its utilization review (UR) delegates must review all services that require a medical necessity review. UCare sends a denial, termination, or reduction (DTR) letter to the member any time services that require prior authorization and review of medical necessity according to UCare s prior authorization grid are denied, terminated, or reduced. A DTR of these services requires review and determination by a UCare Medical Director. The current (sending) CC is required to: Complete the DHS-6037 form and send or fax the form to the new CC delegate (receiver) as soon as the enrollment with the new delegate is indicated on the enrollment roster, but no later than the 15 th calendar day of the month. Include the following supporting case documentation with the DHS-6037 form: o Current assessment(s). o POC. o Relevant case notes. The receiving CC is required to: Contact the transferred member within 10 calendar days of assignment, by letter or phone, to introduce the new CC. Review the DHS-6037 form, assessments, and current POC with the member and document this review in the member s record. Identify when the next assessment is due. Reassessments should be kept on schedule, based on the previous assessment date per MMIS. Complete a new assessment and POC if unable to obtain a copy of the most recent assessment and POC from the previous CC. Notify UCare by completing the Death Notification form found on UCare s website. 8.1.18 10
Documentation Requirements Policies and Procedures Complete the DHS-5181form and send it to the county financial worker. If any of the care coordination requirements were attempted but not completed, the CC is required to document all attempts in the plan of care and/or progress notes. All UCare delegates are required to have policies and /or procedures that support all the above stated requirements. 8.1.18 11