Or. Admin. Code § 410-141-3865 - Care Coordination: Identification of Member Needs
(1) In order to coordinate a Member's
services as described in this rule, OAR
410-141-3860 and OAR
410-141-3870, Coordinated Care
Organizations (CCOs) must have mechanisms in place to identify the Member's
physical, developmental, behavioral, oral and social needs (including Health
Related Social Needs (HRSN) and Social Determinants of Health and Equity
(SDOH-E)), goals, and preferences of Members on an initial and ongoing
basis.
(2) CCOs must conduct an
initial Health Risk Assessment (HRA), as defined in OAR
410-141-3500, with subsequent
documented attempts as described in sub-paragraph (f) (A) of section (2) of
this rule, within ninety (90) days of enrollment, or sooner if a Member's
health status requires, and must:
(a) Conduct
the HRA according to the evaluation checklist provided by the Oregon Health
Authority (OHA) and available on the CCO Contract Forms page;
(b) Make the HRA available to members, their
representative or guardian orally, in writing, or online;
(c) Document all attempts made to reach the
Member in accordance with OAR
410-141-3520;
(d) Review and document a Member's HRA in
their Care Profile or the member's general health care record, if applicable,
in accordance with OAR
410-141-3870(4)(h);
(e) Share with other entities and providers
serving the member the results of any HRA to reduce duplication of those
activities; and
(f) When the
Member, their representative or guardian has not returned or responded to the
HRA, the CCO must:
(A) Follow up with the
Member if additional information, or support with completion, is needed. This
shall include;
(i) Making a minimum of two (2)
additional attempts to contact the Member to facilitate completion and
identification of the Member's needs; and
(ii) The attempts to reach a Member shall
utilize two (2) mixed modalities (e.g., paper, digital or verbal), on different
days and at different times; and
(iii) Shall be in the Member's preferred
method of communication and language. Auxiliary Aids and Services and Alternate
Formats must be made available upon request.
(B) Use other available data sources,
including but not limited to those identified in OAR
410-141-3860(8) and
(3) of this rule, to identify sufficient
information to assign a risk level to the Member; and
(C) Ensure services are coordinated for
members regardless of their participation in or completion of the
HRA.
(3) CCOs
shall consider relevant information from a variety of sources to inform the
development or update of a Member's Care Profile, and/or Care Plan, if
applicable, as described in OAR
410-141-3870(4) and
(5). This includes, but is not limited to:
(a) Progress notes from any entity involved
in the Members care coordination team;
(b) Any relevant assessments;
(c) New medical diagnoses, courses of
treatment, rising or emergent needs;
(d) Social needs (including Health Related
Social Needs (HRSN) and Social Determinants of Health and Equity
(SDOH-E))
(e) Utilization of
services as a result of claims review;
(f) Information received from the Member,
their representative or guardian or other involved providers or community
supports.
(g) Change in
health-related circumstances which is defined as, but not limited to, any of
the following occurrences:
(A) Hospital ER
visits, hospital admissions or discharges (including Institutions for Mental
Disease);
(B) Crisis Services
(i.e., Mobile Crisis response, Mobile Response and Stabilization
Services);
(C) High-Risk Pregnancy
diagnosis;
(D) Newly diagnosed or
significant change to a Chronic disease or condition;
(E) Newly diagnosed or significant change to
a Behavioral health diagnosis or condition;
(F) Newly diagnosed or significant change to
an Intellectual/Developmental Disability (I/DD) diagnosis;
(G) Event that poses a significant risk to
the Member that is likely to occur, reoccur or escalate without
intervention;
(H) Recent
homelessness, or at risk for homelessness or non-placement;
(I) Two or more billable primary ICD-10 Z
code diagnoses within one (1) month resulting in a change in health status
and/or risk level;
(J) Two or more
caregiver placements within past six (6) months;
(K) Discharge from carceral settings (i.e.,
state or federal prisons, local correctional facilities, juvenile detention
facilities or Tribal correctional facilities), back to the community or another
residential or care setting;
(L)
Admit to or discharge from a residential or long-term care setting back to the
community or another care setting;
(M) Exit from Condition Specific Program or
Facility as defined in OAR
410-141-3500;
(N) Enrollment or disenrollment in other
service programs such as Long-Term Services and Supports (LTSS),
Intellectual/Developmental Disability (I/DD) services or Children's Intensive
In-home services;
(O) Orders for
Home Health or Hospice services;
(P) Newly identified or change to an
identified Health Related Social Need (HRSN);
(Q) An identified gap in network adequacy
that leaves the Member without a needed service or care;
(R) Life span developmental transitions such
as a transition from pediatric to adult health care;
(S) Entry into, discharge from, instability,
or placement disruption while in foster care.
(4) CCOs must implement mechanisms, including
but not limited to the HRA and any additional relevant assessments described
above, to identify the risk level and needs for:
(a) Members with Special Health Care Needs
(SHCN) as defined in OAR
410-120-0000 and
(b) Members requiring Medicaid Funded Long
Term Services and Supports (LTSS) as defined in OAR
410-141-3500.
(5) If at any time the Member is
identified as potentially eligible for, or requiring LTSS, or having a Special
Health Care Need, the CCO must also ensure those members are comprehensively
assessed, per 42 CFR
438.208(c)(2), as soon as
their health condition requires, to identify those members who have an ongoing
special condition that requires either a course of treatment or regular care
monitoring.
(6) CCOs must ensure
appropriate and prompt referral of Members identified in (5) of this rule to
the Oregon Department of Human Services (ODHS), including Aging and People with
Disability (APD) programs, the Office of Developmental Disabilities Services
(ODDS), Local Mental Health Authorities (LMHA) or other service programs where
appropriate for completion of a comprehensive assessment and potential service
planning.
Notes
Statutory/Other Authority: 414.615, 414.625, 414.635, 414.651 & ORS 413.042
Statutes/Other Implemented: ORS 414.610-414.685
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.