Appropriate Nursing Facility Institutionalization The Contractor must have and comply with written protocols for nursing facility admissions and report institutional utilization data. The protocols must include the following activities: Identify medical conditions and patient profiles that differentiate between Enrollees at risk of being institutionalized and those who require institutional care; Develop monitoring and risk-assessment mechanisms that assist the PCP or PCT to identify Enrollees at risk of institutionalization; Implement processes that link Initial and Ongoing Assessments to the timely provision of appropriate preventive care and treatment interventions to at-risk Enrollees. Such protocols must emphasize continuity of care and coordination of services. The protocols must be based upon an evaluation of the outcomes and costs of care; Implement processes to ensure the timely provision of nursing facility services when necessary; Identify and formalize the linkages present between the PCPs, PCTs, and the long term care Providers of home- and community-based services, and how these linkages encourage and support maintaining Enrollees in their communities as long as appropriate; and For individuals who can safely and adequately be cared for in the community, implement a Discharge Planning program that begins at the point of admission to any institution, to ensure the earliest appropriate discharge to community long term care. Substance Abuse Prevention and Treatment Initiative The Contractor must have and comply with written protocols to prevent, identify, and treat substance abuse and a reporting system that produces utilization data. Protocols must include the following: Written practice guidelines, in accordance with accepted clinical guidelines, to treat substance abuse and evaluate the effectiveness of the treatment; Distribution of the practice guidelines and measurement of compliance with the practice guidelines on the part of the Contractor, the PCPs, and any PCTs; Procedures for identifying Enrollees who are currently abusing substances including narcotics and alcohol or at risk for abuse; and Documentation of coordination between the PCP or PCT and the behavioral health Provider.
Appropriate Nursing Facility Institutionalization The Contractor must have and comply with written protocols for nursing facility admissions and report institutional utilization data. The protocols must include the following activities: Identify medical conditions and patient profiles that differentiate between Enrollees at risk of being institutionalized and those who require institutional care; Develop monitoring and risk-assessment mechanisms that assist the PCP or PCT to identify Enrollees at risk of institutionalization; Implement processes that link Initial and Ongoing Assessments to the timely provision of appropriate preventive care and treatment interventions to at-risk Enrollees. Such protocols must emphasize continuity of care and coordination of services. The protocols must be based upon an evaluation of the outcomes and costs of care; Implement processes to ensure the timely provision of nursing facility services when necessary; Identify and formalize the linkages present between the PCPs, PCTs, and the long term care Providers of home- and community-based services, and how these linkages encourage and support maintaining Enrollees in their communities as long as appropriate; and For individuals who can safely and adequately be cared for in the community, implement a Discharge Planning program that begins at the point of admission to any institution, to ensure the earliest appropriate discharge to community long term care. Substance Abuse Prevention and Treatment Initiative The Contractor must have and comply with written protocols to prevent, identify, and treat substance abuse and a reporting system that produces utilization data. Protocols must include the following: Written practice guidelines, in accordance with accepted clinical guidelines, to treat substance abuse and evaluate the effectiveness of the treatment; Distribution of the practice guidelines and measurement of compliance with the practice guidelines on the part of the Contractor, the PCPs, and any PCTs; Procedures for identifying Enrollees who are currently abusing substances including narcotics and alcohol or at risk for abuse; and Documentation of coordination between the PCP or PCT and the behavioral health Provider.