2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Long-Term Carebudget plan are sufficient to meet themember's needs. The criteria used to makethis determination include one or more of thefollowing:• The service is essential to enable themember to attain, maintain, or regain hisor her optimal functional capacity.• The service addresses a need related toimproving the member's health, functionaloutcomes, or quality-of-life outcomes.• The service addresses environmentalsafety or a safety-related long-term careneed.• The service enables the member toincrease or maximize his or herindependence.• The service delays or prevents the needfor more expensive institutionalplacement.• The service is not available from anothersource.The care coordinator identifies one or moresources of covered services and supportsavailable to meet identified long-term careneeds, including one or more HCBS primaryproviders and backup providers/plans if theHCBS primary provider becomes unavailable.The care coordinator considers the views andchoices of the member or the member’srepresentative regarding the proposedservices and considers any other relevantinformation from qualified professionals, themember’s HCBS providers, and others whenauthorizing services.A comprehensive individual reassessment of allindividuals receiving HCBS takes place at leastevery six months, incorporating a reassessment ofthe HCBS plan. NF LOC eligibility reassessmenttakes place at least annually and within fivebusiness days of notification to PHP that themember’s functional or medical status has changedin a way that may affect LOC determination.Transitions of CareFor members in out-of-home care or transitioning toa nursing facility, Presbyterian’s care coordinatorparticipates in the facility’s care planning anddischarge planning/transition processes,advocating that the member be managed in theleast restrictive setting and coordinating services tohelp support the member’s transition back to thecommunity as appropriate.CommunicationTo ensure a truly integrated delivery system ofcare, Presbyterian requires and relies on ourproviders to communicate with each other and withthe Presbyterian care coordination staff. Themember’s care coordinator is accountable forfacilitating this communication, sharing the careplan with all providers, and conducting ICPTmeetings and interactions. All providers involved ina member’s care are responsible for participating inthese care coordination efforts, providing updateson the member’s status and progress toward careplan goals, and making referrals andrecommendations as appropriate. PresbyterianCentennial Care offers web-based technologies tosupport our providers and community-based10-122014 Practitioner and Provider Manual - Ver. 3