Provision of 24/7 Care managers will rotate The care redesign access to care on-call duty. coordinator will review Vendor will handle off the on-call duty rotation hour Calls meeting schedule and the call criteria will be forwarded to logs. This is reported on a care manager on call. the quarterly CRP report Each care manager will template. supply their cell number to the patients and will handle their own patients off hours call. Completion of HRA Care partner office will Tracked by care upon CCIP provide HRA to beneficiary manager and reported enrollment to complete. The HRA will to the care redesign be completed and coordinator. Supervisors discussed in office visit will review a sample of after program acceptance during routine staff by beneficiary. review. Care manager will telephonically complete the HRA with the patient and transmit to the care partner for discussion in the enrollment Identification of ADL Care manager/member of Tracked by care and IADL care management team. manager. Supervisors deficiencies Other PDP office staff using will review a sample of standardized assessment cases during routine tool staff review. Identification of Care manager/member of Tracked by care community care management team. manager. Supervisors resources and other Other will review a sample of non-medical during routine staff providers to address review. patient need, connect patient to resource, and document outcome. Completion of the Care manager/member of Completion is tracked by care plan. care management team. care manager and Other reported to the care
Provision of 24/7 access to care Care managers will rotate on-call duty. Vendor will handle off hour Calls meeting criteria will be forwarded to a care manager on call. Each care manager will supply their cell number to the patients and will handle their own patients off hours call. The care redesign coordinator will review the on-call duty rotation schedule and the call logs. This is reported on the quarterly CRP report template. Completion of HRA upon CCIP enrollment Care partner office will provide HRA to beneficiary to complete. The HRA will be completed and discussed in office visit after program acceptance by beneficiary. Care manager will telephonically complete the HRA with the patient and transmit to the care partner for discussion in the enrollment Tracked by care manager and reported to the care redesign coordinator. Supervisors will review a sample of during routine staff review. Identification of ADL and IADL deficiencies Care manager/member of care management team. Other PDP office staff using standardized assessment tool Tracked by care manager. Supervisors will review a sample of cases during routine staff review. Identification of community resources and other non-medical providers to address patient need, connect patient to resource, and document outcome. Care manager/member of care management team. Other Tracked by care manager. Supervisors will review a sample of during routine staff review. Completion of the care plan. Care manager/member of care management team. Other Completion is tracked by care manager and reported to the care
CCIP%20IP%20Template%20-%202018%20Draft%20Completed%20Sample.docx