Or. Admin. R. 410-141-3865 - Care Coordination Requirements

Current through Register Vol. 60, No. 12, December 1, 2021

(1) CCOs will ensure continuous care management for all members.
(2) For the purpose of OARs 410-141-3860 - 410-141-3870, the following meanings apply:
(a) "Health Risk Screening" means:
(A) A systematic collaborative approach by the CCO and provider to collecting information from a Member about key areas of their health for the purpose of:
(i) Assessing the Member's health,
(ii) Evaluating the Member's level of health risk, and
(iii) Providing the Member with individualized feedback about the results of the screening and evaluation with the goal of motivating behavioral changes to reduce health risks, maintain health, and prevent disease.
(B) Results of the Health Risk Screening shall be documented in the member's care plan.
(C) Health Risk Screenings are usually administered through a survey or questionnaire. Suggested areas of information to collect include questions, depending on the Member's age, regarding:
(i) Demographics, such as age, gender, relationship status;
(ii) Lifestyle behaviors, such as exercise, eating habits, alcohol and tobacco use, activities of daily living;
(iii) Living Conditions such as access to food, housing and related living conditions;
(iv) Behavioral/emotional health, such as stress, mood, life events, abuse;
(v) Physical health, such as weight, height, blood pressure; and
(vi) Personal and family health history.
(b) "Intensive Care Coordination (ICC) Assessment" means the utilization of standardized tools, instruments, or processes for the purpose of identifying, and creating individual, personalized treatment and service plans to address the specific physical, behavioral, oral, and social needs of Priority Population Members, as well as other Members who have been identified, as a result of their Health Risk Screenings, as potentially in need of ICC Services, or having experienced a triggering event as set forth in OAR 410-141-3870(9).
(3) CCOs shall conduct a health risk screening, which shall include a screening for behavior health issues, for each new member in accordance with OAR 410-141-3870. This screening is distinct from the assessment of special health care needs:
(a) CCOs must use a screening process to evaluate all members for critical risk factors that trigger the need for intensive care coordination for members with special health care needs;
(b) Members shall be screened upon initial enrollment with their CCO. This screening shall be completed as follows:
(A) Within 90 days of the effective date of initial enrollment;
(B) Within 30 days of the effective date of initial enrollment when the member is:
(i) Referred; or
(ii) Receiving Medicaid-funded long-term care, services and supports (LTSS); or
(iii) Is a member of a priority population as such term is defined in OAR 410-141-3870(2); or
(C) Sooner than required under (A) or (B) if required by the member's health condition.
(c) CCOs shall rescreen members annually or sooner if there is a change in health status indicating need for an updated assessment. Members shall be rescreened in accordance with this section (c) even if they have previously declined care coordination or ICC services;
(d) If a member's health risk screening indicates that they meet criteria for ICC services, the CCO shall conduct, in accordance with OAR 410-141-3870, an ICC assessment within 30 days of completing the health risk screening;
(e) All Screenings and assessments shall be trauma-informed, culturally responsive and linguistically appropriate and person-centered.
(4) CCOs shall document all screenings and assessments in the member's case file:
(a) If a CCO requires additional information from the member to complete a screening or assessment, the CCO shall document all attempts to reach the member by telephone and mail;
(b) CCOs shall maintain all screening and assessment documentation in accordance with OAR 410-141-3520;
(c) CCOs shall share the results of member assessments and screenings consistent with ORS 414.679 and all other applicable state and federal privacy laws with the following:
(A) Participating medical providers serving the member, who are encouraged to integrate the resulting care plan into the individual's medical record;
(B) The state or other MCEs serving the member;
(C) Members receiving LTSS and, if approved by the member, their case manager and their LTSS provider, if approved by the member; and
(D) With Medicare Advantage or DSNP plans serving dual eligible members.
(5) CCOs shall have processes to ensure review of a member's potential need for long-term services and supports (LTSS) and for identifying those members requiring referral to the Department for LTSS.
(6) CCOs shall require their care coordinators to develop, and CCOs shall require their provider network to use, individualized care plans to the extent feasible to address the supportive and therapeutic needs of each member, particularly those with ICC needs, including those with serious and persistent mental illness receiving home and community-based services covered under the state's 1915(i) State Plan Amendment and those receiving LTSS.
(7) A member's care plan must at a minimum:
(a) Incorporate information from treatment plans from providers involved in the member's care, and, if appropriate and with consent of the member, information provided by community partners;
(b) Contain a list of care team members, including contact information and role, compiled in cooperation with the member;
(c) Make provision for authorization of services in accordance with OAR 410-141-3835;
(d) For members enrolled in ICC or a condition-specific program, intensive care coordination plans (ICCP) must be developed within 10 days of enrollment in the ICC program and updated every 90 days, or sooner if health care needs change.
(8) Care plans must reflect the member's preferences and goals, and if appropriate, family or caregiver preferences and goals:
(a) Care plans shall be trauma-informed, culturally responsive and linguistically appropriate and person-centered;
(b) To ensure engagement and satisfaction with care plans, care coordinators shall:
(A) Actively engage members in the creation of care plans;
(B) Ensure members understand their care plans; and
(C) Ensure members understand their role and responsibilities outlined in their care plans.
(c) Care coordinators shall actively engage caregivers in the creation of member care plans and shall ensure that they understand their role as outlined in the care plan and that they feel equipped to fulfill their responsibilities;
(d) If participation in creating a member's care plan would be significantly detrimental to the member's care or health, the member, the member's caregiver, or the member's family may be excluded from the development of a care plan. The CCO must document the reasons for the exclusion, including a specific description of the risk or potential harm to the member, and describe what attempts were made to ameliorate the risk(s). This decision must be reviewed prior to each plan update, and the decision to continue the exclusion shall be documented as above;
(e) Members shall be provided a copy of their care plan at the time it is created, and after any updates or changes to the plan. However, if providing the member with a copy of their care plan would be significantly detrimental to their care or health, the care plan may be withheld from the member. CCOs must document the reasons for withholding the care plan, including a specific description of the risk or potential harm to the member, and describe what attempts were made to ameliorate the risk(s). This decision must be reviewed prior to each plan update, and the decision to continue withholding the care plan shall be documented as above.
(9) A member may decline care coordination and ICC. CCOs shall explicitly notify members that participation in care coordination or ICC is voluntary, and that treatment or services cannot be denied as a result of declining care coordination.
(10) Care coordinators shall perform their care coordination tasks in accordance with the following principles:
(a) Use trauma informed, culturally responsive and linguistically appropriate care, motivational interviewing, and other patient-centered tools to actively engage members in managing their health and well-being;
(b) Work with members to set agreed-upon goals with continued CCO network support for self-management goals;
(c) Promote utilization of preventive, early identification and intervention, and chronic disease management services;
(d) Focus on prevention, and when prevention is not possible, manage exacerbations and unanticipated events impacting progress toward the desired outcomes of treatment;
(e) Provide evidence-based condition management and a whole person approach to single or multiple chronic conditions based on goals and needs identified by the individual;
(f) Promote medication management, intensive community-based services and supports and, for ICC members, peer-delivered services and supports; and
(g) Have contact with, if the member is participating in a condition-specific program, the active condition-specific care team at least twice per month, or sooner if clinically necessary for the member's care.
(11) Care coordinators shall promote continuity of care and recovery management through:
(a) Episodes of care, regardless of the member's location;
(b) Monitoring of conditions and ongoing recovery and stabilization;
(c) Adoption of condition management and a whole person approach to single or multiple chronic conditions based on the goals and needs identified by the individual, including avoidance and minimization of acute events and chronic condition exacerbations; and
(d) Engaging members, and their family and caregivers as appropriate.
(e) For FBDE members, engagement of member Medicare providers and, when applicable, member Medicare Advantage or DSNP care coordination team, in order to reduce duplication, share assessments, coordinate NEMT, address member language or disability access needs, coordinate referrals, and ensure effective transitions of care.
(12) CCOs must facilitate transition planning for members. In addition to the requirements of 410-141-3860, care coordinators shall facilitate transitions and ensure applicable services and appropriate settings continue after discharge by taking the steps set forth below.
(a) Taking an active role in discharge planning from a condition-specific facility including, without limitation, acute care or behavior rehabilitation services facilities.
(b) For discharges from the State Hospital and residential care, the care coordinator shall do all of the following:
(A) Have contact with the member no less than two times per month prior to discharge and two times within the week of discharge;
(B) Assist in the facilitation of a warm handoff to relevant care providers during transition of care and discharge planning; and
(C) Engage with the member, face to face, within two days post discharge.
(c) For discharges from an acute care admission, the care coordinator shall have contact with the member on a face-to-face basis whenever possible, as follows:
(A) Within one business day of admission;
(B) Two times per week while the member is in acute care; and
(C) No less than two times per week within the week of discharge.
(d) Prior to discharge from any residential, inpatient, long-term care, or other similarly licensed care facility, care coordinators shall conduct a transition meeting to facilitate development of a transition plan for both applicable services and appropriate settings. This meeting must be held 30 days prior to the member's return to the CCO's service area or, if applicable, to another facility or program or as soon as possible if the CCO is notified of impending discharge or transition with less than 30 days' advance notice. The discharge plan must include a description of how treatment and supports for the member will continue;
(e) In the event a member has a lapse in Medicaid coverage while admitted to a hospital, residential, inpatient, long-term care, or other similarly licensed in-patient facility, CCOs must also, in addition to providing the services set forth in subsections (a)-(d) of this section (12) of this rule, oversee management of the member's care, work to establish services that may be needed but currently are not available in their service areas, and if eligible, assist in the reinstatement of Medicaid coverage. The CCO's obligation to provide such services shall continue for the period of 60 days from the date the member lost Medicaid coverage or until the member's discharge, whichever occurs sooner.
(13) CCOs shall ensure care coordinators are providing the required and appropriate behavioral, oral, and physical health care services and supports to members. The individual(s) tasked with responsibility for supervising care coordinators, whether employed by a CCO or employed by a Subcontractor providing care coordination services, shall be a licensed master's-level mental health professional. CCOs shall not subcontract or otherwise delegate the responsibility for ensuring any subcontracted care coordination services and activities meet the requirements set forth in this rule, OARs 410-141-3860, 410-141-3870, and any other applicable care coordination requirements.


Or. Admin. R. 410-141-3865
DMAP 57-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021

Statutory/Other Authority: 414.615, 414.625, 414.635, 414.651 & ORS 413.042

Statutes/Other Implemented: ORS 414.610-414.685

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