Or. Admin. Code § 410-141-3865

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-141-3865 - Care Coordination: Identification of Member Needs

(1) In order to coordinate a member's services as described in this rule, OAR 410-141-3860 and OAR 410-141-3870, Coordinated Care Organizations (CCOs) must have mechanisms in place to identify the member's physical, developmental, behavioral, dental and social needs (including Health Related Social Needs and Social Determinants of Health and Equity), goals, and preferences of members on an initial and ongoing basis.

(2) CCOs must conduct a Health Risk Assessment (HRA) within ninety (90) days of enrollment, or sooner if a member's health condition requires, and must:

(a) Conduct the HRA according to the evaluation checklist provided by the Oregon Health Authority (OHA) and available on the Quality Assurance Material Submission and Review page;

(b) Make the HRA available to members, their representative or guardian orally, in writing, or online;

(c) Document all attempts made to reach the member in accordance with OAR 410-141-3520;

(d) Review and document a member's HRA in their Care Profile or Care Plan, if applicable, in accordance with OAR 410-141-3870;

(e) Share with other entities and providers serving the member the results of any HRA to prevent duplication of those activities; and

(f) When the member, their representative or guardian has not returned or responded to the HRA, the CCO must:

(A) Follow up with the member if additional information, or support with completion, is needed. This shall include making a minimum of three (3) attempts to contact the member to facilitate completion and identification of the member's needs. The attempts to reach a member shall utilize at least two (2) mixed modalities (e.g., telephonic, text, email, letter), on different days, and at different times;

(B) Use other available data sources, including but not limited to those identified in OAR 410-141-3860(8) and (3) of this rule, to identify sufficient information to assign a risk level to the member; and

(C) Ensure services are coordinated for members regardless of their participation in or completion of the HRA.

(3) CCOs shall consider relevant information from a variety of sources to inform the development or update of a member's Care Profile, and/or Care Plan, if applicable, as described in OAR 410-141-3870 (4) and (5). This includes, but is not limited to:

(a) Progress notes from any entity involved in the members care coordination team;

(b) Any relevant assessments;

(c) New medical diagnoses, courses of treatment, and emergent needs;

(d) Social needs (including Social Determinants of Health and Health Related Social Needs)

(e) Utilization of services as a result of claims review;

(f) Information received from the member, their representative or guardian or other involved providers or community supports.

(g) Change in health-related circumstances which is defined as, but not limited to, any of the following occurrences:

(A) Hospital ER visits, hospital admissions or discharges;

(B) Mobile Crisis response;

(C) Pregnancy diagnosis;

(D) Chronic disease diagnosis;

(E) Behavioral health diagnosis;

(F) Intellectual/Developmental Disability (I/DD) diagnosis;

(G) Event that poses a significant risk to the member that is likely to occur or reoccur without intervention;

(H) Recent, or at risk for, homelessness or non-placement;

(I) Two or more billable primary ICD-10 Z code diagnoses within one (1) month;

(J) Two or more caregiver placements within past six (6) months;

(K) Discharge from a correctional facility, juvenile detention facility, other residential or long-term care settings back to the community or another care setting;

(L) Exit from Condition Specific Program or Facility as defined in OAR 410-141-3500;

(M) Enrollment or disenrollment in other service programs such as Long-Term Services and Supports, Intellectual/Developmental Disability services or Children's Intensive In-home services;

(N) Orders for Home Health or Hospice services;

(O) Newly identified or change to an identified Health Related Social Need (HRSN);

(P) An identified gap in network adequacy that leaves the member without a needed service or care;

(Q) Life span developmental transitions such as a transition from pediatric to adult health care;

(R) Entry into, or change of placement while in, foster care.

(4) CCOs must implement mechanisms, including but not limited to the HRA and any additional relevant assessments described above, to identify the risk category and needs for:

(a) Members with Special Health Care Needs (SHCN) as defined in OAR 410-141-3500; and

(b) Members requiring Medicaid Funded Long Term Services and Supports (LTSS) as defined in OAR 410-141-3500.

(5) If at any time the member is identified as potentially eligible for, or requiring LTSS, or having a Special Health Care Need, the CCO must also ensure those members are comprehensively assessed, per 42 CFR 438.208(c)(2), as soon as their health condition requires, to identify those members who have an ongoing special condition that requires either a course of treatment or regular care monitoring.

(6) CCOs must ensure appropriate and prompt referral of CCO-identified LTSS members to Oregon Department of Human Services (ODHS) Aging and People with Disability (APD) programs, the Office of Developmental Disabilities Services (ODDS), Local Mental Health Authorities (LMHA) or other service programs where appropriate.

Or. Admin. Code § 410-141-3865

DMAP 57-2019, adopt filed 12/17/2019, effective 1/1/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021; DMAP 56-2021, amend filed 12/30/2021, effective 1/1/2022; DMAP 89-2022, amend filed 12/16/2022, effective 1/1/2023; DMAP 37-2024, amend filed 01/25/2024, effective 2/1/2024

Statutory/Other Authority: 414.615, 414.625, 414.635, 414.651 & ORS 413.042

Statutes/Other Implemented: ORS 414.610-414.685