Model of Care (MOC) Training - Envolve Health · The purpose of this course is to describe how Centene and its providers work together to successfully deliver the Special Needs Model

2019 Model of Care

1. Model of Care Overview

1.1 Medicare: 2019 Model of Care Training

Notes:

Narration:

Welcome to the Model of Care e-Learning.

Published by Articulate® Storyline www.articulate.com

1.2 Introduction

Notes:

Narration:

The purpose of this course is to describe how Centene and its providers work together to successfully deliver the Special Needs Model of Care (MOC) program.

Citation:

Centene Marketing Stock Image


1.3 Course Goals

Notes:

Narration:

At the end of this course, you will be able to:

Outline the basic components of the Centene Model of Care (MOC)

Explain how Centene Medical Management staff coordinates care for Special Needs Plan (SNP) members

Describe the essential role of providers in the implementation of the MOC program

Define the critical role of the provider as part of the MOC Interdisciplinary Care Team (ICT)

Citation: Web. 3 Mar 2017. <https://pixabay.com/en/goal-football-football-pitch-ball-2042584/>.


https://pixabay.com/en/goal-football-football-pitch-ball-2042584/

https://pixabay.com/en/goal-football-football-pitch-ball-2042584/

1.4 Model of Care Training

Notes:

Narration:

The Model of Care (MOC) is Centene’s comprehensive plan for delivering our integrated care management program for members with special needs.

The Affordable Care Act requires the National Committee for Quality Assurance to review and approve all Special Needs Plans Model of Care Plans using standards and scoring criteria established by Centers for Medicare and Medicaid (CMS)

This course is offered to meet the CMS regulatory requirements for Model of Care training for our Special Needs Plans.

It also ensures all employees and providers who work with our Special Needs Plan members have the specialized training this unique population requires


1.5 Current Medicare Plans

Notes:

Narration:

Centene provides different types of special needs plans all over the country, to include: Dual Special Needs Plans (AKA as D-SNP), Chronic Condition Special Needs Plans (AKA I-SNP), and Medicare-Medicaid Plans (AKA as MMP). These plans all require Model of Care.

Click on each button to the right to learn which health plans are affiliated with each type of Special Needs Plan.

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MMP (Slide Layer)

D-SNP (Slide Layer)


C-SNP (Slide Layer)

1.6 Definition of Model of Care

Notes:

Narration:

So what exactly is a Model of Care? The Model of Care is Centene’s comprehensive plan for delivering our integrated care management program for


members with special needs.

It is the architecture for promoting quality, care management policy and procedures, and operational systems.

Citation: Web. 24 Feb 2017. <https://pixabay.com/en/architecture-iron-steel-building-414035/>.

1.7 Model of Care Elements

Notes:

Narration:

The Model of Care is comprised of four clinical and non-clinical elements:

1. Description of the Special Needs Plan population

2. Care Coordination

3. Special Needs Plan Provider Network

4. Quality Measurements and Performance Improvement

Citation:


https://pixabay.com/en/architecture-iron-steel-building-414035/

https://pixabay.com/en/architecture-iron-steel-building-414035/

Web. 24 Feb 2017. <https://pixabay.com/en/landscape-sky-clouds-drought-1653069/>.

2. Element 1: Description of the Population

2.1 Description of the Population

Notes:

Narration:

Element 1 includes characteristics related to the membership that Centene and providers serve including social factors, cognitive factors, environmental factors, living conditions, and co-morbidities.

This element also includes: determining and tracking eligibility; specialty tailored services for members; and how Centene works with community partners.

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2.2 Types of Special Needs Plans

Notes:

Narration:

Medicare Advantage Special Needs Plans are designed for specific groups of members with special health care needs. CMS has defined three types of Special Needs Plans that serve the following types of members:

Dual Eligible Special Needs Plan (D-SNP)

Chronic Condition Special Needs Plan (C-SNP)

And Institutional Special Needs Plan (I-SNP)

Health plans may contract with CMS for one or more programs. Centene has Dual Eligible Special Needs Plan, Chronic Special Needs Plan and MMP plans.

Citation:



2.3 Special Needs Plans

Notes:

Narration:

Medicare is the primary payer for acute services, unless the service is not covered by Medicare or the Medicare service benefit is exhausted, then Medicaid becomes primary.

Dual Special Needs Plan members have both Medicare and Medicaid but not always with Centene. Medicaid benefits may be through another health plan or the state.

It is important to verify coverage prior to rendering services.

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2.4 MMP Plans Definition and Overview

Notes:

Narration:

Medicare-Medicaid Plans, are a product of combining Medicare and Medicaid. It is a three-way contract between Centers for Medicare and Medicaid (CMS), state Medicaid and Centene as defined in Section 2602 of the Affordable Care Act.

The purpose of the MMP plan is to improve quality, reduce costs, and improve the member experience. Our goal is to:

Ensure dually eligible members have full access to the services they are entitled

Improve coordination between the federal and state government requirements

Develop innovative care coordination and integration models

and eliminate financial misalignments that lead to poor quality and cost shifting


2.5 MMP Plans

Notes:

Narration:

Eligibility rules for Medicare - Medicaid Plans vary from state to state, however, general eligibility guidelines must be met.

Members must be eligible for Medicare and Medicaid, and have no private insurance.

Medicare - Medicaid Plan members have full Medicare and Medicaid rights and benefits

The Medicare and Medicaid benefits are integrated as one benefit with Centene coordinating services and payment.

Citation: Web. 1 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=985&q=me

MMP members have full Medicare and Medicaid rights and benefits.


https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1920&bih=985&q=me

2.6 Specific Services

Notes:

Narration:

Centene provides members with services tailored to the needs of the Special Needs and Medicare - Medicaid Plan populations. Click on the buttons to the left to learn more about these special services.

Citation: Web. 1 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=member


https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=190&bih=950&q=member

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3. Element 2: Care Coordination

3.1 Care Coordination

Notes:

Narration:

The Care Coordination element includes a description of how the Special Needs Plan will coordinate health care needs and preferences of the member, and share information with the Interdisciplinary Care Team.

Centene conducts care coordination using the Health Risk Assessment (HRA), an Individualized Care Plan (ICP), and providing an Interdisciplinary Care Team for the member.

The Care Coordination element also includes:

An explanation of all persons involved in care

A contingency plan to avoid disruption in care

and training that is required of all involved in member care and how it is administered

Citation:



3.2 Health Risk Assessment

Notes:

Narration:

A Health Risk Assessment is conducted to identify medical, psychosocial, cognitive, functional and mental health needs of members.

The initial Health Risk Assessment will be completed in person, telephonically or by mail within 90 days of enrollment and annually, or if there is a change in the member’s condition or transition of care

Health Risk Assessment responses are used to: identify needs, are incorporated into the member’s care plan, and communicated to the Interdisciplinary Care Team

Changes in health condition and annual updates are used to update the care plan

Note: Physicians should encourage members to complete the Health Risk Assessment in order to better coordinate care and create an individual care plan.

Citation:


Web. 1 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=clipboard

3.3 Individualized Care Plan Overview

Notes:

Narration:

An Individualized Care Plan (ICP) is developed by the Interdisciplinary Care Team (ICT) in collaboration with the member

Care Managers and Primary Care Physicians work closely together with the member and their family to prepare, implement, and evaluate the Individualized Care Plan (ICP)

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ICP (Slide Layer)

CM (Slide Layer)


3.4 Individualized Care Plan

Notes:

Narration:

Individualized Care Plans include problems, interventions, measurable goals, as well as services the member may receive. Services include:

Medical condition management

Long term services and supports (members with LTSS benefits)

Skilled nursing, DME, home health

Occupational therapy, physical therapy, speech therapy

Behavioral health and substance use disorder

Transportation

Other services as needed

Citation:

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Medical Condition Management (Slide Layer)

LTSS (Slide Layer)

by Articulate® Storyline www.articulate.com Published

Skilled Nursing (Slide Layer)

OT, PT, ST (Slide Layer)


Behavioral Health (Slide Layer)

Transportation (Slide Layer)


Other Services (Slide Layer)

3.5 Interdisciplinary Care Team

Notes:

Narration:

Centene Care Managers coordinate the member’s care with the Interdisciplinary Care Team (ICT) based on the member’s preference of who they wish to attend.


The Interdisciplinary Care Team includes:

Primary Care Physician or specialist

The member and their family/caregiver

Centene staff - such as care manager, pharmacist, behavioral health, and medical director

And it also includes ancillary providers involved in the member’s care such as therapists and home care staff.

Centene Care Managers work with the member to encourage self-management of their condition, as well as communicate the member’s progress toward these goals to the other members of the Interdisciplinary Care Team.

Citation:


3.6 Interdisciplinary Care Team

Notes:

Narration:

Centene’s program is member centric with the Primary Care Physician being the


primary point of contact for the Interdisciplinary Care Team.

Centene staff works with all members of the Interdisciplinary Care Team in coordinating the plan of care for the member.

3.7 ICT and Inpatient Care

Notes:

Narration:

During an episode of illness, members may receive care in multiple settings, often resulting in fragmented and poorly executed transitions.

Centene staff manage transitions of care to ensure that members have appropriate follow-up care after a hospitalization or change in level of care to prevent re-admissions.

Citation: Web. 2 Mar 2017. <https://pixabay.com/en/hospital-hospital-corridor-921034/>.


https://pixabay.com/en/hospital-hospital-corridor-921034/

3.8 Care Manager Responsibilities

Notes:

Narration:

The Care Manager has several responsibilities in regards to coordinating the member’s care with the Interdisciplinary Care Team. Click on each button to the right to learn more about these responsibilities.

Coordinate with facilities to assist members in the hospital or in a skilled nursing facility to access care at the appropriate level.

Collaborate with the facility and the member or the member’s representative to develop a discharge plan.

Proactively identify members with potential for readmission and enroll them in case management.

Notify the PCP of the transition of care and anticipated discharge date and discharge plan of care.

Citation:

Base Layer:


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Coordinate Layer:


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Collaborate (Slide Layer)

Identify (Slide Layer)


Notify (Slide Layer)

3.9 TOC Interventions

Notes:

Narration:

Managing Transitions of Care (TOC) interventions for all discharged members may include, but is not limited to:


Face-to-face or telephonic contact with the member or their representative in the hospital prior to discharge to discuss the discharge plan

In-home visits or phone call within 72 hours post discharge

And ongoing education of members to include preventative health strategies in order to maintain care in the least restrictive setting possible for their health care needs

Citation:


3.10 Post Discharge Outreach

Notes:

Narration:

In-home visits or phone calls are done to:

Evaluate member’s understanding of their discharge plan

Assess member’s understanding of their medication plan

Ensure follow up appointments have been made

Make sure the home situation supports the discharge plan


3.11 ICT Responsibilities

Notes:

Narration:

The Interdisciplinary Care Team has several other responsibilities.

Centene works with each member to:

Develop their personal goals and interventions for improving their health outcomes

Monitor implementation and barriers to adherence with the physician’s plan of care

Identify and anticipate problems and act as the liaison between the member and their PCP

Identify needs for Long Term Services and Supports (LTSS) and coordinate services as applicable

Coordinate care and services between the member’s Medicare and Medicaid benefit

Educate members about their health conditions and medications and empower them to make good healthcare decisions

prepare members/caregivers for their provider visits. Encourage the use of a


personal health record

Refer members to community services as identified

Notify the member’s physician of planned and unplanned transitions

Citation:

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Develop (Slide Layer)

Monitor (Slide Layer)


Anticipate (Slide Layer)

Identify (Slide Layer)



Educate (Slide Layer)


Prepare (Slide Layer)

Refer (Slide Layer)


Notify (Slide Layer)

3.12 Provider ICT Responsibilities

Notes:

Narration:

As mentioned previously, the Primary Care Physician is the primary point of contact for the Interdisciplinary Care Team.

Click on the buttons on the left to learn more about their responsibilities.


Provider responsibilities include:

Accept invitations to attend member’s ICT meetings whenever possible

Maintain copies of the ICP, ICT worksheets, and transition of care notifications in the member’s medical record when received

Collaborate and actively communicate with Centene Case managers; Members of the Interdisciplinary Care Team (ICT); and members and caregivers.

Citation:

Accept Layer: Web. 3 Mar 2017. <https://pixabay.com/en/letter-right-now-white-envelope-755126/>. Maintain Layer: Web. 3 Mar 2017. <https://pixabay.com/en/file-folders-business-office-desk-923523/>.

Collaborate Layer: Web. 3 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=communicate&oq=communicate&gs_l=img.3..0l10.502.1930.0.2106. 11.9.0.2.2.0.149.715.8j1.9.0....0...1ac.1.64.img..0.11.721.7Olwrt5i-9A#imgrc=2ShvPDlZh7wJ8M:>.

Accept (Slide Layer)


https://pixabay.com/en/letter-right-now-white-envelope-755126/

https://pixabay.com/en/letter-right-now-white-envelope-755126/

https://pixabay.com/en/file-folders-business-office-desk-923523/

https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1920&bih=950&q=communicate&oq=communicate&gs_l=img.3..0l10.502.1930.0.2106.11.9.0.2.2.0.149.715.8j1.9.0....0...1ac.1.64.img..0.11.721.7Olwrt5i-9A#imgrc=2ShvPDlZh7wJ8M

Maintain (Slide Layer)

Collaborate (Slide Layer)


3.13 CMS ICT Expectations

Notes:

Narration:

Regarding the Interdisciplinary Care Team, CMS expects the following:

That all care is member-centric

Family members and caregivers are included in health care decisions as the member desires

There is continual communication between all members of the ICT regarding the member’s plan of care

All team meetings and communications are documented and stored

Citation: Web. 3 Mar 2017. <https://www.google.com/search?q=CMS&safe=active&biw=1920&bih=985&source= lnms&tbm=isch&sa=X&ved


https://www.google.com/search?q=CMS&safe=active&biw=1920&bih=985&source=lnms&tbm=isch&sa=X&ved

3.14 Contingency Plan

Notes:

Narration:

Natural disasters or emergencies can occur at any time. CMS requires health plans to have a contingency plan in place so they are prepared.

Click on each button to the right to see how disruption can be avoided.

Citation: Web. 3 Mar 2017. <https://www.google.com/search?q=CMS&safe=active&biw=1920&bih=985&source= lnms&tbm=isch&sa=X&ved

P

ublished by Articulate® Storyline www.articulate.com

https://www.google.com/search?q=CMS&safe=active&biw=1920&bih=985&source=lnms&tbm=isch&sa=X&ved

4. Element 3: Provider Network

4.1 Provider Network Description

Notes:

Narration:

Element 3 explains the specialized provider network available to our members.

This element also describes:

How the network meets the needs of the target population

How Centene oversees network facilities

How providers collaborate with the Interdisciplinary Care Team and contribute to a member’s Individualized Care Plan

Citation: Web. 2 Mar 2017. <https://pixabay.com/en/doctor-dentist-dental-clinic-1149149/>.


https://pixabay.com/en/doctor-dentist-dental-clinic-1149149/

4.2 Provider Network

Notes:

Narration:

Centene is responsible for maintaining a specialized provider network that meets the needs of our members.

Centene coordinates care with and ensures that providers:

Collaborate with the Interdisciplinary Care Team

Provide clinical consultation

Assist with developing and updating care plans

Provide pharmacotherapy consultation

P


4.3 CMS Expectations

Notes:

Narration:

In regards to the provider network element, CMS has many expectations. Click on the buttons to the right to learn more about these expectations.

Prioritize contracting with board-certified providers

Monitor network providers use of nationally recognized clinical practice guidelines when available

Assure that the network providers are licensed and competent through a formal credentialing process

Document the process for linking members to services

coordinate the maintenance and sharing of member’s healthcare information among providers and the ICT

Citation:

Base Layer:


Prioritize Layer:



Monitor Layer: Web. 3 Mar 2017. <https://pixabay.com/en/books-library-bookshelf-1920341/>.

Assure Layer: Web. 3 Mar 2017. <http://www.bing.com/images/search?view=detailV2&ccid=QNiBPbdP&id=4E8E2ED3 F3E96B8B79F63ADBC1E2823C5E3704ED

Document Layer: Web. 3 Mar 2017. <https://pixabay.com/en/laptop-hands-computer-technology-1149412/>.

Coordinate Layer:

Prioritize (Slide Layer)


https://pixabay.com/en/books-library-bookshelf-1920341/

http://www.bing.com/images/search?view=detailV2&ccid=QNiBPbdP&id=4E8E2ED3F3E96B8B79F63ADBC1E2823C5E3704ED

https://pixabay.com/en/laptop-hands-computer-technology-1149412/

https://pixabay.com/en/laptop-hands-computer-technology-1149412/

Monitor (Slide Layer)

Credential (Slide Layer)


Document (Slide Layer)



5. Element 4: Quality Measurement and Performance

Improvement

5.1 Quality Measurement and Performance Improvement

Notes:

Narration:

Element 4 requires health plans to have performance improvement quality measurement plans in place.

To evaluate success, Centene disseminates evidence-based clinical guidelines and conducts studies to:

Measure member outcomes

Monitor quality of care

And evaluate the effectiveness of the Model of Care (MOC)

Citation: Web. 6 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=quality+improvement&oq=quality+improvement&gs_l=img.3..0l10. 973.3205.0.3373.19.10.0.9.9.0.115.718.8j1.9.0....0...1ac.1.64.img..1.18.757.2BMriqcfb es#safe=active&hl=en&tbm=isch&q=quality+measurement&*&imgrc=AAmWJJhXFm


https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1920&bih=950&q=quality+improvement&oq=quality+improvement&gs_l=img.3..0l10.973.3205.0.3373.19.10.0.9.9.0.115.718.8j1.9.0....0...1ac.1.64.img..1.18.757.2BMriqcfb es#safe=active&hl=en&tbm=isch&q=quality+measurement&*&imgrc=AAmWJJhXFmEZGM

EZGM:>.

5.2 Model of Care Goals and Data Sources

Notes:

Narration:

Centene determines goals that are designed and implemented to measure the effectiveness of the model of care.

Our goals are in alignment with the Medicare and Medicaid regulatory agencies performance measurement systems that include:

Stars

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Healthcare Effectiveness Data and Information Set (HEDIS)

And Health Outcomes Survey (HOS)

P


5.3 Model of Care Goals and Data Sources

Notes:

Narration:

As stated in the previous slide, Centene determines goals for the Model of Care related to the improvement of the quality of care our members receive. These goals may include: access to care, access to preventative health services, member satisfaction and chronic care management.

Citation:


6. Summary

6.1 Summary

Notes:

Narration:

In summary, Centene values our partnership with physicians and providers,

The Model of Care requires all of us to work together to benefit our members by:

Enhanced communication between member’s, physicians, providers, and Centene

Using an interdisciplinary approach to the member’s special needs

Employing comprehensive coordination with all care partners

Supporting the member’s preferences in the plan of care

Reinforcing the member’s connection with their medical home

P


7. Knowledge Check

7.1 Knowledge Check

Notes:

Narration:

We are almost done, but first, let’s take some time to see what you have learned.

Citation:

Web. 3 Feb 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=985&q=adults+taking+a+test&oq=adults+taking+a+test&gs_l=img.3...956.3 900.0.4047.20.12.0.8.8.0.216.1197.5j4j1.10.0....0...1ac.1.64.img..3.13.1072...0j0i24k1.u V9fK3OZGGs#hl=en&tbm=isch&q=scantron+test&imgrc=CLoYj9OvB-fFfM:>.

7.2 What is the Model of Care?

(Multiple Choice, 10 points, 2 attempts permitted)


https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1920&bih=985&q=adults+taking+a+test&oq=adults+taking+a+test&gs_l=img.3...956.3900.0.4047.20.12.0.8.8.0.216.1197.5j4j1.10.0....0...1ac.1.64.img..3.13.1072...0j0i24k1.u V9fK3OZGGs#hl=en&tbm=isch&q=scantron+test&imgrc=CLoYj9OvB-fFfM

Correct Choice

A type of assessment

X Centene’s comprehensive plan for delivering our integrated care management

program for members with special needs

A type of care plan

A report that monitors post discharge outreach for our Medicare members

Feedback when correct:

That's right! You selected the correct response.

Feedback when incorrect:

You did not select the correct response. The Model of Care is Centene’s comprehensive plan for

delivering our integrated care management program for members with special needs

Notes:

Citation:



Correct (Slide Layer)

Incorrect (Slide Layer)


Try Again (Slide Layer)

7.3

Which 4 elements is the Model of Care comprised of? Select all that apply.

(Multiple Response, 10 points, 2 attempts permitted)


Correct Choice

X Description of the SNP Population

Description of the Care Plan

X Care Coordination

Utilization Management

X SNP Provider Network

X Quality Measurements & Performance Improvement




You did not select the correct response. Description of the SNP Population; Care Coordination;

SNP Provider Network; and Quality Measurements & Performance Improvement are the

elements of the Model of Care.

Notes:

Citation: Web. 24 Feb 2017. <https://pixabay.com/en/landscape-sky-clouds-drought-1653069/>.


https://pixabay.com/en/landscape-sky-clouds-drought-1653069/





7.4 True or False. The initial HRA should be completed within 90 days of

enrollment, annually and if there is a change in the member’s condition or

transition of care.

(True/False, 10 points, 2 attempts permitted)


Correct Choice

X True

False




You did not select the correct response. The initial HRA should be completed telephonically

within 90 days of enrollment; annually; and if there is a change in the member’s condition or

transition of care.

Notes:

Citation: Web. 21 Mar 2017. <https://pixabay.com/en/phone-communication-call-select-735062/>.


https://pixabay.com/en/phone-communication-call-select-735062/

https://pixabay.com/en/phone-communication-call-select-735062/





7.5 What is an ICP?


Correct Choice

X Individualized Care Plan


Integrated Care Partners

Individual Care Party




You did not select the correct response. An ICP is an Individualized Care Plan.

Notes:

Citation:






7.6 True or False. Individualized care plans include member-centric

problems, interventions, and goals, as well as services the member will

receive.


Correct Choice

X True

False




You did not select the correct response. Individualized care plans should include member-

centric problems, interventions, goals, and services the member will receive.

Notes:


Citation: Web. 21 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=member+centric&oq=member+centric&gs_l=img.3..0j0i24k1l3.1135. 3017.0.3183.14.13.0.1.1.0.151.1233.8j5.13.0....0...1ac.1.64.img..0.14.1233...0i30k1j0i5i 30k1j0i8i30k1.L5ToBG3-Ocw#imgrc=EPspV5IMfWrXyM:>.



https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1920&bih=950&q=member+centric&oq=member+centric&gs_l=img.3..0j0i24k1l3.1135.3017.0.3183.14.13.0.1.1.0.151.1233.8j5.13.0....0...1ac.1.64.img..0.14.1233...0i30k1j0i5i 30k1j0i8i30k1.L5ToBG3-Ocw#imgrc=EPspV5IMfWrXyM



7.7 Which of the following is a responsibility of the Care Manager?



Correct Choice

Coordinate with facilities to assist members in the hospital or in a skilled nursing

facility to access care at the appropriate level.

Work with the facility and the member or the member’s representative to develop

a discharge plan.

Proactively identify members with potential for readmission and enroll them in

case management.

X All of the above




You did not select the correct response. All of the above are the responsibilities of the Care

Manager.


Notes:

Citation: Web. 7 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=985&q=elements&oq=elements&gs_l=img



https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=1920&bih=985&q=elements&oq=elements&gs_l=img



7.8 Who should be involved with the Interdisciplinary Care Team?



Correct Choice

Mental Health Provider

Primary Care Provider

Case Manager

Specialty Provider

X All of the Above




You did not select the correct response. The member’s mental health provider, primary care

provider, specialty provider and care coordinator should all be involved with the ICT.

Notes:

Citation:


Web. 20 Mar 2017. <https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=problems+goals+and+interventions




https://www.google.com/search?hl=en&site=imghp&tbm=isch&source=hp&biw=19 20&bih=950&q=problems+goals+and+interventions


7.9 Transition of Care in-home visits or phone calls are done to:


Correct Choice

Evaluate member’s understanding of their discharge plan


!ssess member’s understanding and adherence of their medication plan

Ensure follow up appointments have been made

Make certain the home situation supports the discharge plan

X All of the above




You did not select the correct response. In-home visits or phone calls are done to evaluate

member’s understanding of their discharge plan- assess member’s understanding of their

medication plan; ensure follow up appointments have been made; and make certain the home

situation supports the discharge plan.





7.10 True or False. Centene works with each member to develop their

personal goals and interventions for improving their health outcomes.



Correct Choice

X True

False




You did not select the correct response. Centene does work with each member to develop their

personal goals and interventions for improving their health outcomes.

Notes:

Citation:







7.11 What are the responsibilities of the Interdisciplinary Care Team?

Select all that apply.

(Multiple Response, 10 points, 2 attempts permitted)


Correct Choice

X Educate members about their health conditions and medications and empower

them to make good healthcare decisions

X Refer members to community resources as identified

X Identify Long Term Services and Supports (LTSS) needs and coordinate services as

applicable

X Identify problems and act as the liaison between the member and their PCP




You did not select the correct response.

Notes:

Citation:







7.12 True or False. CMS expects there to be continual communication

between all members of the ICT regarding the member’s plan of care.



Correct Choice

X True

False




You did not select the correct response. CMS expects there to be continual communication

between all members of the ICT regarding the member’s plan of care.

Notes:

Citation:






7.13 True or False. Providers should try to attend Interdisciplinary Care

Team meetings and actively communicate with the members of the ICT.



Correct Choice

X True

False




You did not select the correct response. Providers should try to attend ICT meetings and

actively communicate with the other members.

Notes:

Citation: Web. 21 Mar 2017. <https://pixabay.com/en/tie-necktie-coat-doctor-hospital-216992/>.


https://pixabay.com/en/tie-necktie-coat-doctor-hospital-216992/

https://pixabay.com/en/tie-necktie-coat-doctor-hospital-216992/





7.14 Centene coordinates care with and ensures that providers:


Correct Choice

Collaborate with the Interdisciplinary Care Team


Provide Clinical Consultation

Assist with developing and updating care plans

Provide pharmacotherapy consultation

X All of the Above




You did not select the correct response. Centene coordinates care with and ensures that

providers collaborate with the ICT; provide clinical consultation; assist with developing and

updating care plans; and provide pharmacotherapy consultation.

Notes:

Citation: Web. 21 Mar 2017. <https://pixabay.com/en/doctor-tomograph-i-am-a-student-1228627/>.


https://pixabay.com/en/doctor-tomograph-i-am-a-student-1228627/

https://pixabay.com/en/doctor-tomograph-i-am-a-student-1228627/





8. Results

8.1 Results Slide

(Results Slide, 0 points, 1 attempt permitted)


Results for

7.2 What is the Model of Care?

7.3

Which 4 elements is the Model of Care comprised of? Select all that apply.

7.4 True or False. The initial HRA should be completed within 90 days of enrollment, annually

and if there is a change in the member’s condition or transition of care.

7.5 What is an ICP?

7.6 True or False. Individualized care plans include member-centric problems, interventions,

and goals, as well as services the member will receive.

7.7 Which of the following is a responsibility of the Care Manager?

7.8 Who should be involved with the Interdisciplinary Care Team?

7.9 Transition of Care in-home visits or phone calls are done to:

7.10 True or False. Centene works with each member to develop their personal goals and

interventions for improving their health outcomes.

7.11 What are the responsibilities of the Interdisciplinary Care Team? Select all that apply.

7.12 True or False. CMS expects there to be continual communication between all members of

the ICT regarding the member’s plan of care.

7.13 True or False. Providers should try to attend Interdisciplinary Care Team meetings and

actively communicate with the members of the ICT.

7.14 Centene coordinates care with and ensures that providers:


Result slide properties

Passing 90%

Score

Success (Slide Layer)


Failure (Slide Layer)


http://www.articulate.com

Documents

Model of Care (MOC) Training - Envolve Health · The purpose of this course is to describe how Centene and its providers work together to successfully deliver the Special Needs Model