D.C. Mun. Regs. tit. 22, r. 22-A2507

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

Rule 22-A2507 - CARE COORDINATION

2507.1

Care Coordination is the facilitation or implementation of the comprehensive care plan through appropriate linkages, referrals, coordination and follow-up to needed services and support. Care Coordination provides assistance with the identification of individual strengths, resources, preferences and choices. Care Coordination is a function shared by the entire Health Home Team and may involve, but is not limited to, the facilitation or implementation of the following:

(a) Developing strategies and supportive mental health intervention for avoiding out-of-home placement and building stronger family support skills and knowledge of the consumer's strengths and limitations;

(b) Providing telephonic and other electronic reminders of appointments;

(c) Providing telephonic consults and outreach;

(d) Communicating with family members;

(e) Identifying outstanding items on patient visit summaries such as referrals, immunization, self- management goal support and health education needs;

(f) Assisting with medication reconciliation;

(g) Making appointments;

(h) Providing patient education materials;

(i) Assisting with arrangements such as transportation, directions and completion of durable medical equipment requests;

(j) Obtaining missing records and consultation reports;

(k) Participating in hospital and emergency room (ER) transition care;

(l) Coordination with other health care providers to ensure screenings follow- up is completed;

(m) Coordinating with Fire and Emergency Medical Services to promote appropriate utilization of emergency medical and transport services; and

(n) Ensure that consumers continue connections to and maintain eligibility for any public benefit to which the beneficiary may be entitled, including Medicaid.

D.C. Mun. Regs. tit. 22, r. 22-A2507

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