Or. Admin. R. 410-141-3870 - Intensive Care Coordination

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

(1) CCOs are responsible for Intensive Care Coordination (ICC) services. The requirements described in this rule are in addition to the general care coordination requirements and health risk screenings described in OAR 410-141-3860 and 410-141-3865.
(2) "Prioritized Populations" means individuals who:
(a) Are older adults, individuals who are hard of hearing, deaf, blind, or have other disabilities;
(b) Have complex or high health care needs, or multiple or chronic conditions, or SPMI, or are receiving Medicaid-funded long-term care services and supports (LTSS);
(c) Are children ages 0-5:
(A) Showing early signs of social/emotional or behavioral problems, or
(B) Have a Serious Emotional Disorder (SED) diagnosis;
(d) Are in medication assisted treatment for SUD;
(e) Are women who have been diagnosed with a high-risk pregnancy;
(f) Are children with neonatal abstinence syndrome;
(g) Children in Child Welfare;
(h) Are IV drug users;
(i) People with SUD in need of withdrawal management;
(j) Have HIV/AIDS or have tuberculosis;
(k) Are veterans and their families; and
(L) Are at risk of first episode psychosis, and individuals within the Intellectual and developmental disability (IDD) populations.
(3) "Intensive Care Coordinator" (ICC Care Coordinator) means a person coordinating ICC services as defined in this rule.
(4) "Intensive Care Coordination Plan" (ICC Plan) means a collaborative, comprehensive, integrated and interdisciplinary-focused written document that includes details of the supports, desired outcomes, activities, and resources required for an individual receiving ICC Services to achieve and maintain personal goals, health, and safety. It identifies explicit assignments for the functions of specific care team members, and addresses interrelated medical, social, cultural, developmental, behavioral, educational, spiritual and financial needs in order to achieve optimal health and wellness outcomes.
(5) All members of prioritized populations shall be automatically assessed for ICC services within 10 calendar days of completion of the health risk screening, or sooner if required by their health condition. Children who are members of a prioritized population shall be provided behavioral health services according to presenting needs.
(6) CCOs shall also conduct an ICC assessment of other members, including children age 18 and under, upon referral or after an initial-health risk screening as set forth below in this section (6). All referrals for ICC assessments shall be responded to by the CCO within one business day of receipt of the referral and the ICC assessment shall be completed within 30 days after receipt of referral or completion of an initial health-risk screening. ICC assessments shall be conducted when:
(a) A health risk screening conducted under, and in accordance with, OAR 410-141-3865 indicates a member has special health care needs or other needs or conditions that may indicate a need for ICC services;
(b) A member refers themselves;
(c) A member's representative or provider, including a home and community- based services provider, refers the member; or
(d) Upon referral of any medical personnel serving as a member's LTCSS case manager.
(7) CCOs shall have policies and procedures in place that enable early identification of members who may have ICC needs. CCOs shall have established process for responding to all requests for ICC assessments or services, which shall include, without limitation, the requirement to respond to all requests or referrals for ICC assessments or services within one business day.
(8) ICC assessments shall identify the physical, behavioral, oral and social needs of a member.
(9) For those members not receiving ICC services, and upon the occurrence of any of the reassessment triggering events listed below in subsections (c)(A) through (S) of this section (9), CCOs shall conduct new health risk screenings, and, as applicable, reassess members for ICC eligibility revise care plans, and ensure care coordination efforts are undertaken in accordance with OAR 410-141-3865. Contact shall be made with the member by the care coordinator within seven calendar days of receipt of notice of the reassessment triggering event:
(a) For those members receiving ICC services and upon the occurrence of any of the triggering events listed below in subsections (b)(A) through (S) of this section (9), ICC care coordinators shall, if in the ICC care coordinator's professional opinion it is necessary to reassess the members for ICC services, update the members' ICC plan, and ensure care coordination efforts are undertaken in accordance with OAR 410-141-3865 and this rule. Contact shall be made with the member by the ICC care coordinator within three calendar days of receipt of notice of a reassessment triggering event;
(b) Reassessment triggering events include all of the following events:
(A) New hospital visit (ER or admission);
(B) New high-risk pregnancy diagnosis;
(C) New chronic disease diagnosis (includes behavioral health);
(D) New behavioral health diagnosis;
(E) Opioid drug use;
(F) IV drug use;
(G) Suicide attempt, ideation, or planning (identification may be through the member's care team, through diagnoses, or from the member or member's supports);
(H) New I/DD diagnosis;
(I) Events placing the member at risk for adverse child experiences, such as DHS involvement or new reports of abuse or neglect to Child Welfare Services or Adult Protective Services;
(J) Recent homelessness;
(K) Two or more billable primary Z code diagnoses within one month;
(L) Two or more caregiver placements within past six months;
(M) An exclusionary practice, such as being asked not to return to day care, for children aged 0-6, or suspension, expulsion, seclusion, or in-school suspension, for school-aged children;
(N) Discovery of new or ongoing behavioral health needs;
(O) Discharge from a residential setting or long-term care back to the community;
(P) Severe high level of self-reported or detected alcohol or benzodiazepine usage while enrolled in a program of medication assisted treatment;
(Q) Two or more readmissions to an acute care psychiatric hospital in a 6-month period;
(R) Two or more readmissions to an emergency department for a psychiatric reason in a 6-month period; and
(S) Exit from condition-specific program.
(c) Members shall be reassessed for ICC services and care plans or, if applicable, ICC plans shall be revised annually;
(d) Reassessment for ICC services and care plans, or if applicable, ICC plans, revised if necessary, must be performed upon member request.
(10) Members eligible for ICC shall be assigned an ICC care coordinator:
(a) ICC Care coordinator assignments must be made within three business days of determining a member is eligible for ICC services;
(b) If a member is in a condition-specific program at the time they are determined eligible for ICC services, or enters a condition-specific program while receiving ICC services, then the CCO will appoint the care coordinator of the condition-specific program as the ICC care coordinator for the member while the member is in the condition-specific program. After a member transitions from a condition-specific program, the CCO must reassess the member for ICC services within seven calendar days of the transition and assign a new ICC care coordinator within three business days of the completion of the ICC reassessment;
(c) CCOs shall notify members of their ICC status by at least two means of communication within five business days following the completion of the ICC assessment. Notifications shall include details about the ICC program and the name and contact information of their assigned ICC care coordinator.
(11) CCOs shall implement procedures to share the results of ICC assessment including, without limitation, identifications made as a result of the assessment and intensive care coordination plan (ICCP) created for ICC services. CCOs shall share the results with participating providers serving the member, other parties identified in OAR 410-141-3865 and, for members receiving LTCSS, the results should be shared with the local offices for aging and adults with physical disabilities (APD) and the Office of Developmental Disability Services. Information sharing shall be consistent with ORS 414.679 and applicable state and federal privacy laws and meet timely access standards set forth in in 410-141-3515.
(12) ICC services shall include, without limitation:
(a) Assistance to ensure timely access to and management of medical providers, capitated services, and preventive, physical health, behavioral health, oral health, remedial, and supportive care and services;
(b) Coordination with medical and LTCSS providers to ensure consideration is given to unique needs in treatment planning;
(c) Assistance to medical providers with coordination of capitated services and discharge planning; and
(d) Aid with coordinating necessary and appropriate linkage of community support and social service systems with medical care systems.
(13) ICC Care coordinators must provide the following services:
(a) Meet face to face with the member, or make multiple documented attempts to do so, for the initial and exiting appointments. Thereafter, ICC care coordinators must have face-to-face contact with the member individually at least once every three months and make other kinds of contact (face to face when possible) three times a month or more frequently if indicated. If an ICC care coordinator is unable to comply with the member contact requirements, the CCO must document attempts made, barriers, and remediation efforts taken to overcome the barriers to the member contact requirements;
(b) Contact the member no more than three calendar days after receiving notification of a reassessment trigger described in section (9) of this rule. If an ICC care coordinator is unable to make contact with the member within three calendar days of a reassessment trigger, the ICC care coordinator must document in the member's case file all efforts made to contact the member. ICC care coordinators must continue brief contacts with members who have experienced a reassessment trigger as long as deemed necessary by the care team before they revert back to the routine contact requirements under subsection (a) of this section (13);
(c) Contact the member's Primary Care Provider (PCP) within one week of ICC assignment, no less than once a month thereafter, or more often if required by the member's circumstances, to ensure integration of care;
(d) Facilitate communication between and among behavioral and physical health service providers regarding member progress and health status, test results, lab reports, medications, and other health care information when necessary to promote optimal outcomes and reduce risks, duplication of services, or errors. This communication shall provide an interdisciplinary, integrative and holistic care update, including a description of clinical interventions being utilized and member's progress towards goals;
(e) Convene and facilitate interdisciplinary team meetings monthly, or more frequently, based on need. Interdisciplinary team meetings must include the member unless the member declines or the member's participation is determined to be significantly detrimental to the member's health, in accordance with OAR 410-141-3865(7)(d). The ICC care coordinator is responsible for arranging for the PCP or PCP staff to bring material to the meeting. The meetings shall provide a forum to:
(A) Describe the clinical interventions recommended to the treatment team;
(B) Create a space for the member to provide feedback on their care, self-reported progress towards their ICC plan goals and their strengths exhibited in between current and prior meeting;
(C) Identify coordination gaps and strategies to improve care coordination with the member's service providers;
(D) Develop strategies to monitor referrals and follow-up for specialty care and routine health care services, including medication monitoring; and
(E) Align with the member's individual ICC plan.
(f) Convening a post-transition meeting of the interdisciplinary team within 14 days of a transition between levels, settings or episodes of care.
(14) If a member is enrolled in other programs, including condition-specific programs, where there is a care manager, the ICC care coordinator remains responsible for the overall care of the member, while the program-specific care manager shall be responsible for supporting specific needs based on their specialty within the interdisciplinary team.
(15) CCOs shall implement processes for documenting all of the ICC services provided and attempted to be provided to members and for creating and implementing ICC plans for members requiring ICC services. CCOs shall produce ICC plans for each member requiring ICC services. Each ICC plan shall:
(a) Be developed in a person-centered process with providers caring for the member, including any community-based support services and LTSS providers and the member's participation;
(b) Include consultations with any specialist(s) caring for the member and Medicaid funded long-term services and supports providers and case managers or for full benefit dual eligible (FBDE) members, Medicare providers or MCE aligned Medicare Advantage or Dual Special Needs Plan care coordinators;
(c) Be approved by the CCO in a timely manner if CCO approval is required;
(d) In alignment with rules outlined in OAR 410-141-3835 CCO Service Authorization; and
(e) In accordance with any applicable quality assurance and utilization review standards.
(16) CCOs shall periodically inform all participating providers of the availability of ICC and other support services available for members. CCOs shall also periodically provide training for patient-centered primary care homes and other primary care provider staff.
(17) CCO staff providing or managing ICC care coordination services shall be required to:
(a) Be available for training, regional OHP meetings, and case conferences involving OHP clients (or their representatives) in the CCO's service areas who are identified as being of a prioritized population;
(b) If a Member is unable to receive services during normal business hours, the CCO shall provide alternative availability options for the member;
(c) Be trained for, and exhibit skills in, person-centered care planning and trauma informed care; and communication with and sensitivity to the special health care needs of priority populations. CCOs shall have a written position description for its staff responsible for managing ICC services and for staff who provide ICC services;
(d) CCOs shall have written policies that outline how the level of staffing dedicated to ICC is determined. The ICC policies must include, without limitation, care coordination staffing standards such that the complexity, scope, and intensity of the needs of members receiving ICC services can be met.
(18) Consistent with the requirements under this rule, CCOs shall make Integration and Care Coordination services available during normal business hours, Monday through Friday. Information on ICC services shall be made available when necessary to a member's representative during normal business hours, Monday through Friday. If a Member is unable to receive services outside of normal business hours, the CCO shall provide alternative availability options for member.
(19) CCOs shall have a process to provide members with special health care needs who are receiving ICC services or are receiving Medicaid-funded LTSS with direct access to a specialist, e.g., a standing referral or an approved number of visits, as appropriate for the member's condition and identified needs. CCOs shall have processes in place to ensure it reviews member needs for LTSS and mechanisms to identify and refer to the Department of human services, inclusive of its area agency on aging, office of developmental disabilities services, and aging and people with disability programs, or, as may be applicable to a 1915(i) provider for LTSS assessment and services.


Or. Admin. R. 410-141-3870
DMAP 57-2019, adopt filed 12/17/2019, effective 01/01/2020; DMAP 1-2020, temporary amend filed 01/02/2020, effective 01/02/2020 through 06/29/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021

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

Statutes/Other Implemented: ORS 414.610 - 414.685

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