2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care CoordinationFamily members or other persons withsignificant involvement in the member’s carePeer/family support specialistsCommunity health workers or communityhealth representativesPharmacistsPresbyterian’s medical directorBehavioral health (mental health andsubstance abuse treatment) cliniciansSpecialty providersClinical staff from nursing homes and assistedliving facilities where members live are alsoincluded as integral participants in the member’sICPT. Residential care staff employees areinstrumental participants in the member’s careteam, and play a central role in alerting carecoordinators to a change in a member’s conditionor status that, if acted upon in a timely andappropriate fashion, may prevent unnecessaryhospitalizations.Members are encouraged to actively participate inthe care planning process, and are provided withtools and resources that allow them to takepersonal responsibility for their care management.The care plan is reviewed, modified if necessary,and approved by the member.ICPT communication may occur through in-personcase conferences, by telephone, or electronicallythrough the care management system. Themember’s assigned care coordinator works with theprovider to ensure that the provider’s input andrecommendations are incorporated into the careplan where appropriate.Ongoing Care CoordinationThe assigned care coordinator is responsible formanaging ongoing care coordination and ensuringthat documentation of care coordination activities ismaintained in the member’s care managementsystem record. These activities are conducted inaccordance with the care plan, and include, at aminimum, the responsibility toDevelop and update the care plan as neededProvide disease management interventionsand health education related to chronicconditionsMonitor treatment and coordinate with theprovider to encourage best practice as itrelates to tests, appointment frequency, andadherence to clinical practice guidelines andcondition-specific protocolsAs appropriate, educate the member and themember’s caregivers about advancedirectives and psychiatric advance directives,and document the member’s decision in thecare management system recordMonitor the member’s participation in careplan activities and recommended servicesMaintain ongoing communication withcommunity and natural supports to monitorand support ongoing participation in themember’s careIdentify non-covered services needed topromote the member’s health, safety, andwell-being, and enlist communityorganizations to provide those services andsupports6-82014 Practitioner and Provider Manual - Ver. 3