Provider Care Coordination

The Regional Accountable Entity (RAE, also known as regional organization) recognizes that care coordination is a fundamental practice for achieving high quality and cost-effective health care outcomes, particularly for members with one or more chronic conditions. We believe that care coordination is most effectively delivered in the patient-centered medical home (PCMH). Optimal care coordination provides timely access to services, enhances continuity of care across providers and care systems, provides support to individual members and their families, and helps them understand and advocate for necessary services.

The regional organization has identified several key strategies that will enhance care coordination for our members and help them obtain the best possible treatment outcomes and maintain overall wellness. One such strategy is to build alliances with community health partners. These alliances begin with patient-centered medical homes, including our community health centers, also referred to as Federally Qualified Health Centers or FQHCs, and Community Mental Health Center/CMHC partners.

Beyond these initial alliances, the regional organization is committed to developing relationships with schools, housing resources, local and regional hospitals, skilled nursing facilities (SNFs) or acute care facilities (ACFs), transportation services, child welfare systems, criminal-justice involved individuals (jails/prisons), and independent health care and behavioral health care providers. By developing and strengthening these community connections, the regional organization establishes a forum for communication to enhance the care for our members.

A second strategy for improving care coordination is to identify sub-groups of members who are at greatest risk for unfavorable health care. For example, the regional organization uses data mining approaches to identify members who are cost outliers, those who have significant medical and psychiatric co-morbidity, and those who have histories of emergency services over-utilization. Identification of these subgroups will continue to evolve as the regional organization gathers data about how our members are using health care services.

A third strategy for improving care is to identify opportunities for preventive care and early intervention. We believe that early care is the best care and that coordinated planning and member education pay dividends in improved health care outcomes.

Northeast Health Partners is responsible for connecting Health First Colorado members with both primary care and behavioral health services. Northeast Health Partners delegates primary responsibility for care coordination activities to its Accountable PCMPs, and other healthcare entities, but is ultimately responsible for oversight of these activities. This oversight is demonstrated through Northeast Health Partners as the central point of contact for making referrals, tracking/monitoring, and auditing to ensure the reporting requirements are met.

Through our delegation model, members have immediate and continuous access to care coordination staff who are dedicated to providing care coordination services. Care coordinators meet on a regular basis to review cases, share information about community resources, and combine resources to meet members’ needs.

All Accountable PCMPs/delegated care coordination entities are responsible for completing an assessment with the member to determine medical and non-medical needs in order to link members to appropriate resources. Accountable PCMPs/delegated care coordinators will provide both deliberate and extended care coordination services. Deliberate interventions are available to the broader population and include tactics such as medical and social referrals, telephonic/electronic communications, educational resources, etc. Extended care coordination targets specific member groups who require more intense and prolonged assistance and includes interventions such as care planning, face-to-face visits, etc.

The Accountable PCMPs/delegated care coordinator is responsible for assessing or arranging for the assessment of the member’s need for services, coordinating mental health services rendered by multiple providers, coordinating behavioral health services with other health care and human service agencies and providers, and referring to other health care and human service agencies and providers, as appropriate. The care coordinator will share the results of their assessment with other providers to prevent duplication of services and reduce the potential for fraud, waste, and abuse.

The Accountable PCMPs/delegated care coordination entities to manage the members physical and behavioral health and use this expanded scope to interface with LTSS providers, and collaborate with social, educational, justice, recreational, and housing agencies to foster healthy communities and address complex member needs that span multiple agencies and jurisdictions. Accountable PCMPs/delegated Care Coordination Entities to assign care coordination to a specific staff person to function as the single point of contact with the different systems and settings related to the member.

The designated staff have an appropriate level of knowledge of the assigned system/setting to serve that population and solve Care Coordination problems for that population. Accountable providers/delegated care coordination entities ensure they are providing specific guidance to care coordinators about each setting, regarding how to identify members in the system/setting; how to provide care coordination services in the system/setting; and how to communicate with contact people in the system/setting to plan transitions, coordinate services, and address issues and member concerns.

These providers/entities also ensure care coordination is accessible to all attributed members, provided at the point of care whenever possible, addresses both short and long-term health needs, is culturally responsive, respects members preferences, and links members to both medical and non-medical, community-based services, such as child care, food assistance, elder support services, housing, utilities assistance, and other non-medical supports. These providers/entities support regular communication between care coordinators and the practitioners delivering services to members.

Accountable Providers/CC Entities also develop and maintain comprehensive knowledge and working relationships with community agencies, health teams, and providers that offer a range of services including medical care, specialty care, hospitals, pharmacists, NEMT, public health, regional health alliances, substance abuse and mental health treatment, legal services, long-term care, dental services, developmental disability services, homeless services, school, and educational programs. They also engage with other agencies that serve higher-risk populations, such as Area Agencies on Aging, Aging and Disability Resources for Colorado, and other ancillary providers.

It is the expectation that all care coordination entities furnishing services to the member share, as appropriate, the member’s health record with other providers or organizations involved in the member’s care, in accordance with professional standards. This communication expectation will promote continuity of care, prevent unnecessary re-hospitalizations or services at a higher level of care, and facilitate improved communication about the member among providers, facilities, and others who are involved with the member.

Accountable PCMPs/delegated Care Coordination entities also assist members who are transitioning between health care settings and populations served by multiple systems, including, but not limited to, children involved with child welfare, individuals qualify for Health First Colorado transitioning out of the criminal justice system, members receiving LTSS services, and members transitioning out of institutional settings.

Following the comprehensive member assessment, care coordination activities are structured by a clinical Care Plan, a collaborative, living document generated by the member and the care coordinator, which reflects the member’s needs, long-term and short-term goals, and associated resources, supports, providers, and action steps towards reaching their identified goals. The Care Plan should be a co-created framework guided at all times by the member’s wellness and health objectives; and subject to regular, member-centered updates in order to remain pertinent over time as the member’s resources, achievements, and challenges inevitably evolve. The Care Plan will serve as a reference point around which care coordination activities pivot, and will be changed in collaboration with the member if their needs, goals, or circumstances change.

While the Care Plan is a highly individualized, member-facing document, it will include at a minimum the standardized, baseline, evidence-based components articulated in The Contract between the RAE and HCPF for Care Coordination Care Plans. These components are itemized in The Contract and must be included in the member’s Care Plan in order for Care Coordination activities to be recognized by The Department.

Accountable PCMPs/delegated Care Coordination entities are responsible for completing a comprehensive assessment of members assigned to their care. The required assessment identifies elements through regional organization policy and is monitored through an auditing process. Providers get feedback about their performance and are directed to complete additional training, if necessary, to achieve compliance with the regional organization’s standards. Providers will receive training about the needs assessment requirements through the onboarding process and through regularly scheduled webinars or other training programs. Providers are also required to document an individualized care plan/treatment plan that is consistent with the member’s needs identified during the needs assessment process. This documentation is also subject to oversight monitoring from the regional organization. Northeast

Health Partners has specific documentation standards related to Accountable Providers/Care Coordination Entities’ electronic care coordination tool. The care coordination tool must support communication and coordination among members of the provider network and the health neighborhood. The care coordination tool collects and aggregates, at a minimum:

• Name and Medicaid ID of the member for whom care coordination interventions were provided
• Age
• Gender identity
• Race/ethnicity
• Address
• Home/work telephone numbers
• Emergency contacts
• Name of entity or entities providing care coordination, including the member’s choice of lead care coordinator if there are multiple coordinators
• Care coordination notes, activities, and member needs
• Assessment of transportation needs and documentation that the provider helped to arrange transportation when necessary
• Stratification level
• Information that can aid in the creation and monitoring of a care plan for the member, such as clinical history, medications, social supports, community resources, and member goals
• Preventive and recovery-focused services as appropriate, such as relapse prevention, wellness programs, lifestyle changes, and referrals to community resources
• Continuity and coordination of care between the care coordinator (Primary Clinician), consultants, ancillary providers and health care institution/providers, and other community services agencies
• Each record documents the date(s) of follow-up appointments or, as appropriate, discharge plans and summary
• All entries are dated

These standards incorporate Health First Colorado documentation requirements and are considered professional practice. They are intended to ensure the highest quality of care, reduce medical errors, and achieve full compliance with the state as well as Northeast Health Partners’ audit requirements. All providers must maintain a comprehensive record for each member served. At a minimum, the record substantiates the reason for services as well as the quality and progress of care.

Northeast Health Partners oversees these functions to ensure that there is an improvement in members’ experience with their healthcare as well as a reduction in duplication of efforts. Northeast Health Partners will help identify and address potential gaps in meeting the member’s interrelated medical, social, developmental, behavioral, educational, informal support system, financial and spiritual needs in order to achieve optimal health, wellness, or end-of-life outcomes, according to member and family preferences and will assist care coordinators within the RAEs network to bridge multiple delivery systems with state agencies.

Northeast Health Partners has the right to audit treatment records and review both individual and aggregate member data to determine whether care coordination is occurring and whether it is consistent with the member’s needs. When care coordination services are deemed by Northeast Health Partners to be insufficient to meet the member’s needs, it has the right to direct changes to the member’s care plan or to otherwise remedy the observed deficiencies.

Northeast Health Partners has the right and responsibility to assign an individual to act as a care coordinator for any member determined to be high-risk by the Department of Health Care Plan and Financing or by the regional organization itself. Care coordinators shall assist members in resolving problems related to access to care, quality of care, or other concerns. They will inform members about other resources for reporting concerns, including the Health First Colorado ombudsman program, and will follow up appropriately with the member regarding these concerns.

Care Coordination services focus on the whole person, addressing areas of need related to physical health, behavioral health, and social determinants of health. Northeast Health Partners serves as a bridge and connector for our members to needed services and care. Care coordinators are here to help all providers connect members to adjunctive services, including physical health, specialty services, and community care. For assistance, call 888-502-4190 (toll-free).