D.C. Mun. Regs. tit. 22, r. 22-A2506

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-A2506 - COMPREHENSIVE CARE MANAGEMENT

2506.1

One of the goals of the Health Home Program is to maintain and/or improve the health of their population through the delivery of appropriate services. Comprehensive Care Management requires Health Home teams to gather demographic and health data about their consumers and tailor interventions and evidence based practices to meet the specific needs of their population. This population management approach requires the following:

(a) Construction of standardized, evidence-based protocols and clinical pathways for mental health, physical health, social, employment, and economic needs;

(b) Tracking and monitoring of the consumer's health, social and employment status based on the protocols and pathways;

(c) Development and dissemination of reports on satisfaction, health status, cost and quality to guide Health Home service delivery and design;

(d) Development of partnerships with physical health care providers and community-based entities in order to facilitate the sharing of information and timely responses to each consumer's needs; and

(e) Health Homes will use aggregated data to determine levels of consumer engagement, progress toward goals, and adherence to or variance from treatment guidelines. Based on this analysis, Health Homes will prioritize outreach, reminders and notifications to individuals and/or providers. Health Homes will systematically review and report quality metrics, assessment results, and service utilization in order to evaluate health status, service delivery, and consumer satisfaction.

2506.2

Comprehensive Care Management is the assessment and identification of health risks leading to the development and implementation of a care plan that addresses health risks and the individualized needs of the whole person. Care plan development will be led by qualified practitioners operating within their scope of practice with input from members of the Health Home team and external resources. Activities include but are not limited to the following:

(a) Monitoring of the consumer and population health status and service use;

(b) Conduct an assessment of health risks and identification of high risk sub groups;

(c) Collect behavioral, primary, acute and long-term care information from health and social service providers, including but not limited to MHRS Diagnostic Assessments and individual recovery or treatment plans, physical assessments from PCPs, and hospital discharge planners to facilitate the creation of a person-centered care plan for every enrolled individual, that is updated at set intervals (as detailed in the DCMR) and following an unplanned inpatient stay;

(d) Reassessment of health assessment(s) annually or more frequently as required by the consumer's health;

(e) Identification of service needs of consumers and construction of a person-centered comprehensive care plan addressing physical and behavioral health chronic conditions, current health status, and goals for improvement; and

(f) Review and updates persons-centered care plan every one hundred eighty (180) days and as needed.

D.C. Mun. Regs. tit. 22, r. 22-A2506

Final Rulemaking published at 63 DCR 849 (1/22/2016); amended by Final Rulemaking published at 66 DCR 5625 (5/3/2019)