The adequacy of the Respondent’s description of how its respective disease management program will be incorporated into its overall Case Management approach to advance the CMS Plan’s goals. The extent to which the Respondent’s algorithm and risk stratification approach is well defined and describes the data sources that will be utilized and ensures that all children will receive Disease/Case Management. The extent to which the Respondent describes data sources that are incorporated into the risk stratification process that is used for new enrollees. The extent to which the Respondent’s approach includes the use of predictive modeling. The extent to which the Respondent’s approach includes innovative strategies for addressing the unique needs of highly resistant or difficult to serve populations. The adequacy of the Respondent’s description of evidence-based interventions in achieving improved outcomes and enhancing enrollee engagement. The efficacy of the Respondent’s approach in achieving cost savings, cost avoidance, emergency department diversion, increased utilization of ambulatory care settings, transitioning children out of institutional settings, and diverting institutionalization, etc. The extent to which the Respondent’s case management programs include at least the following components: Assessment; Plan of Care development; Diversion from or transition from institutional care as needed; Solution-oriented follow-up after emergency room or institutional care to identify opportunities for care improvement to prevent re-institutionalization; Identification of gaps in care including accessibility issues; Identification of service to support children in their homes; Symptom management; Medication support; Emotional support; Behavior change; Parent training regarding diagnoses, medications, symptoms; Arranging transportation; Communication with schools in the development of an Individual Education Plan, 504 plan or education plan; and Communication/education with providers, including the PCP/specialists. The extent to which the Respondent has described a methodology for evaluating the impact of the case management programs and provided results/data based on previous experience that supports the reduction of potentially preventable events.
The adequacy of the Respondent’s description of how its respective disease management program will be incorporated into its overall Case Management approach to advance the CMS Plan’s goals. The extent to which the Respondent’s algorithm and risk stratification approach is well defined and describes the data sources that will be utilized and ensures that all children will receive Disease/Case Management. The extent to which the Respondent describes data sources that are incorporated into the risk stratification process that is used for new enrollees. The extent to which the Respondent’s approach includes the use of predictive modeling. The extent to which the Respondent’s approach includes innovative strategies for addressing the unique needs of highly resistant or difficult to serve populations. The adequacy of the Respondent’s description of evidence-based interventions in achieving improved outcomes and enhancing enrollee engagement. The efficacy of the Respondent’s approach in achieving cost savings, cost avoidance, emergency department diversion, increased utilization of ambulatory care settings, transitioning children out of institutional settings, and diverting institutionalization, etc. The extent to which the Respondent’s case management programs include at least the following components: Assessment; Plan of Care development; Diversion from or transition from institutional care as needed; Solution-oriented follow-up after emergency room or institutional care to identify opportunities for care improvement to prevent re-institutionalization; Identification of gaps in care including accessibility issues; Identification of service to support children in their homes; Symptom management; Medication support; Emotional support; Behavior change; Parent training regarding diagnoses, medications, symptoms; Arranging transportation; Communication with schools in the development of an Individual Education Plan, 504 plan or education plan; and Communication/education with providers, including the PCP/specialists. The extent to which the Respondent has described a methodology for evaluating the impact of the case management programs and provided results/data based on previous experience that supports the reduction of potentially preventable events.
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