TITLE: INTEGRATION AND COORDINATION OF CARE 

DEFINITIONS:

Member: An Oregon Health Plan client enrolled with Health Share of Oregon. 

Primary Care Provider: Any enrolled provider who has responsibility for supervising, coordinating, and providing initial and primary care within their scope of practice for identified Members, including initiating referrals for care outside their scope of practice, consultations and specialist care, and assuring the continuity of medically appropriate patient care. 

Provider: An individual, facility, institution, corporate entity, or other organization that supplies health services or items, also termed a rendering Provider, or bills, obligates and receives reimbursement on behalf of a rendering Provider, also termed a billing Provider. 

SDOH-E Partner: A single organization, local government, one or more of the Federally-recognized Oregon tribal governments, the Urban Indian Health Program, or a collaborative, that delivers SDOH-E related services or programs, or supports policy and systems change, or both within a CCO’s service area.

Social Determinants of Health and Equity (SDOH-E): SDOH-E encompasses three terms -

(i) The social determinants of health refer to the social, economic, and environmental conditions in which people are born, grow, work, live, and age, and are shaped by the social determinants of equity. These conditions significantly impact length and quality of life and contribute to health inequities; 

(ii) The social determinants of equity refer to systemic or structural factors that shape the distribution of the social determinants of health in communities;

(iii) Health-related social needs refer to an individual’s social and economic barriers to health, such as housing instability or food insecurity. 

Subcontractor: An entity that has entered into a contract with Health Share of Oregon to perform designated work under the Health Plan Services Contract. 

PURPOSE: To ensure the development and implementation of a continuum of care for Health Share of Oregon (Health Share) Members that integrates mental health, substance use disorder, oral health and physical health services, and health related social care needs, to achieve the objectives of whole person, integrated care. 

POLICY: 

I. Health Share believes that integrated care spans a continuum ranging from communication to coordination to co-management to co-location to fully integrated team-based care in medical or behavioral health homes or patient centered primary care homes. 

A. Health Share ensures continuous care management by Subcontractors for all Members through episodes of care, regardless of the physical location of the Member.

B. Subcontractors are required to coordinate physical health, behavioral health, intellectual and developmental disability and ancillary services between settings of care, including appropriate discharge planning for short-term and long-term hospital and institutional stays that reduce duplication of assessment and care planning activities. 

II. Subcontractors are required to ensure Member access to coordinated care services that provide effective wellness and prevention services, a Member- and family-centered approach to all aspects of care; and an emphasis on whole-person care in order to comprehensively address Members’ physical, behavioral, and oral health care needs as well as health-related social care needs.

III. Subcontractors shall ensure sufficient and appropriate staffing of the care coordination functions with staff who have the necessary training and expertise to coordinate the physical, behavioral, oral health, and health-related social care needs of Members.

IV. In support of an integrated model of care, Subcontractors are required to provide the following elements of care management:

• Initial health risk screening for each new Member within 90 days of enrollment and within 30 days for Members referred for or receiving Long Term Services and Supports or identified as a Member of a priority population;
• The development of an individualized care plan as indicated that addresses the supportive, therapeutic, cultural and linguistic health needs of each Member;
• Support for an appropriate flow of information across behavioral, dental and physical health Subcontractors and Provider networks;
• Support for an appropriate flow of information to enable effective coordination of community-based resources to address Members’ health-related social needs;
• Implementation of person-centered care coordination and treatment planning and a standardized approach to effective transition planning;
• Use of culturally and linguistically appropriate tools and evidence-based and innovative strategies to ensure coordinated and integrated person-centered care, including individualized care plans reflecting Member preferences and goals, and integration of Traditional Health Workers (THWs), to ensure engagement and satisfaction; and
• Support for contracted Providers in developing the tools and skills necessary to communicate in a linguistically and culturally appropriate manner with Members. Facilitation and coordination of referrals to address Social Determinants of Health and Equity (SDOH-E).
  
  V. The following principles must be considered by Subcontractors when providing care coordination:
  • Use of trauma informed care that is culturally responsive and linguistically appropriate; utilizes motivational interviewing and other patient centered tools to engage the Member in managing their health and wellbeing;
  • Agreed upon goals for self-management;
  • Promote preventive, early identification and intervention and chronic disease management;
  • Use of evidence-based condition management, medication management, community-based services;
  • Twice monthly program specific care team meetings or sooner when appropriate; 
  • Promotion of continuity of care and recovery management through episodes of care regardless of Member location; and
  • Recognition that care coordination programs are voluntary for Members, and Members may accept or decline to participate at any time.
    
    VI. Health Share requires Subcontractors to participate in and support integration activities such as, but not limited to:
  • Communication and coordination between behavioral, dental and physical health Providers; intellectual and developmental disability and ancillary services, Department of Human Services (DHS), Oregon Youth Authority, Oregon and US Department of Veterans Affairs, Members in long term care or Home and Community Based Services, and Fee for Service Medicaid;
  • Integration of Traditional Health Workforce in coordinating care, facilitating care transitions, providing system navigation, and connecting members to services to address health-related social needs.
  • Development of infrastructure support for sharing information, coordinating care and monitoring results, including participation in Health Share sponsored care management and SDOH-E collaboratives;
  • Use of evidence-based screening tools, treatment standards and guidelines that support integration;
  • Support of a culture of collaboration with Health Share, and with behavioral, dental and physical health Providers; and by participating in Health Share governance committees chartered to support the implementation of a system of care approach that is Member driven, community-based, and culturally and linguistically appropriate; and initiatives to address the SDOH-E in line with Community priorities and involving meaningful partnership with SDOH-E Partners
    
    VII. Health Share requires Subcontractors to ensure coordination of the following elements of an integrated system of care:
  • Outpatient mental health and substance use disorder treatment coordinated with physical health care services and oral health care services;
  • Coordination with patient-centered primary care and transition to the most appropriate, independent and integrated care setting, including home and community-based or palliative care settings;
  • Adequate, timely and appropriate access to specialty and hospital services;
  • Systems to assure and monitor transitions in care consistent with Oregon Administrative Rules 410-141-3850 and 3860 such that Members receive comprehensive transitional care, including participation in discharge planning activities and coordination between levels of episodes of care; and
  • Appropriate and effective documentation and communication systems, consistent with the requirements of Oregon Administrative Rule 410-141-3865.
  • Protection of Member privacy consistent with HIPAA section 45 CFR 164.506
    
    VIII. Health Share requires Subcontractors to ensure Members have access to a consistent and stable relationship with a primary care team, an oral health team, a behavioral or medical home, or patient centered primary care home. The teams are responsible for comprehensive care management and transitions, aiding Members in navigating the health care delivery system and in accessing community and social support services and resources.
    
    IX. Health Share requires that Subcontractors have policies and processes in place to ensure that Members are supported during transitions in care.
    
    A. Subcontractors are required to ensure that hospitals and specialty service Providers are accountable for achieving successful transitions of care.
    
    B. Primary care teams are responsible for transitioning members out of hospital settings into the most appropriate, independent, and integrated care settings, including home and community-based as well as hospice and other palliative care settings.
    
    C. In the process of coordinating and supporting transitions in care, each Member’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164, Subparts A and E, to the extent they are applicable. X. Subcontractors shall coordinate services for Members who require health services not covered under the Health Plan Services Contract. Additionally, Subcontractors shall assist Members in gaining access to certain Behavioral Health services that are not covered services, as well as community-based services to address health-related social needs such as supportive housing, food access, and other related activities that promote emotional well-being and social connection. Health Share may provide access to tools that support subcontractors to facilitate SDOH- E resource connection for CCO members, such as the Unite Us closed loop referral platform.
    
    XI. Health Share monitors the performance of Subcontractors on an ongoing basis and performs, at least once a year, a formal review of compliance with all delegated functions, obligations and other responsibilities, performance deficiencies, and areas for improvement.
    
    A. Specific to care coordination activities, the monitoring and review of Subcontractors by Health Share includes:
  • Semi annual reporting to Health Share which includes the requirements listed in OAR 410-141-3860 (19).
  • Grievances related to care coordination with improvement plans designed to address common grievances; and
  • A plan for improvement of the overall process of care coordination including gaps ins services and populations needing care coordination support, and milestones and accomplishments.
    B. If deficiencies are found in Subcontractor performance for these delegated functions, whether identified by Health Share or the Oregon Health Authority, Health Share will require the Subcontractor to respond and remedy those deficiencies within the timeframes determined by the Oregon Health Authority.
    
    REFERENCES:
    45 CFR.160 and 164(A) and (E)
    Health Plan Services Contract Oregon Administrative Rules 410-141-3850, 3860, 3735 and 3865
    Health Share Policy UM-03 Intensive Care Coordination
    Health Share Policy UM-07 Transition of Care Health Share Policy UM-08 Health Screening Health Share/Unite Us Statements of HIPAA Compliance