CalAIM Population Health Management – Transition Care Services
| Date: | February 14, 2024 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Primary Care Providers (PCPs), Specialists, Hospitals and Facilities |
| Type: | Regulatory |
| Subject: | CalAIM Population Health Management – Transition Care Services |
| Business: | Medi-Cal Managed Care |
Health Plan would like to remind providers that Enhanced Care Management Services includes coordination of transitional care services as indicated by the California Advancing and Innovating Medi-Cal (CalAIM) Population Health Management (PHM) Policy Guide, Page 29, Section 3) (Updated October 2023) Transitional Care Services (TCS). Key information has been provided on pages two and three to allow for printing and posting. Please use the site reference for full guidance, https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy-GuideOctober-2023.pdf.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG.
Enhanced Care Management Services – Transitional Care Services, site reference https://www.dhcs.ca.gov/CalAIM/Documents/PHM-Policy-GuideOctober-2023.pdf
1. TCS starts as soon as a transition is identified
Health Plan is responsible for Enhanced Care Management (ECM) and Case Management (CM)
- Notify the assigned Care Manager (ECM Care Manager or CM) of the transition as soon as the MCP is aware that one has occurred (Policy Guide pg. 36-37 “Communication of Assignment to the Care Manager”)
- Communicate this via secure email to the ECM provider’s email of choice using the created template*ECM Providers Responsibility:
- Communicate to the Discharging facility and member the assigned Care Manager’s (ECM CM) contact information to be included in the facility Discharge Instructions whenever possible (Policy Guide pg. 36- 37 “Communication of Assignment to the Care Manager”)
- Request that the facility provide copies of Discharge instructions and Discharge Summary to ECM CM (Policy Guide pg. 37-38 “Coordinating with Discharging Facility to ensure member engagement and comprehensive information sharing and coordination of care”)
2. As soon as a member has been discharged from a transition
(Policy Guide pg. 38 “Necessary Post-Discharge Services and Follow-Ups”)
- Within seven calendar days of DC (TCS Key Performance Indicators [KPIs]):
o Outreach from the designated Care Manager (ECM CM) to assist with any identified care coordination needs.
o Ensure members have an ambulatory (Primary Care) visit. Complete all member care coordination needs, including but not limited to: (Policy Guide pg. 38-39 “Necessary Post-Discharge Services and Follow-Ups”) - Ensure needed services/equipment/medications were ordered on discharge.
o Example: Home health care, DME, or New/changed meds - Make appropriate referrals based on identified needs.
o Example: Community Support Services or Medically Tailored Meals - Assist with connection to the health plan for assistance with any
needed benefits.
o Example: Transportation to/from medical appointments, a change in PCP, or assistance with access to mental health/social work/disease management, et cetera.
3. Post-discharge until the end of TCS
(Policy Guide pg. 38-39 “Necessary Post-Discharge Services and Follow-Ups”)
- Ensure DC follow-up appointments are not only made but kept for PCP & all other involved providers.
- Ensure referrals are received and acted upon
- Remain available to the member for care coordination as outlined above.
4. TCS ends once the member has been connected to all needed services and supports, but no sooner than 30 calendar days from the date of discharge
(Policy Guide pg. 39 “End of TCS for High-Risk Members”)
*Secure Email communication template:
| Member First Name | Member Last Name | Member ID | Admin Date | Admitting Facility | Discharge Date(If applicable) | Admitting Diagnosis |
|---|
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG