Care Conference
Meaningful dialogue with a Patient Navigator, Care Manager, Care Coordinator and a member of the patient's Care Team
What is a Care Conference?
Developed and organized individually based on a patient's unique list of diagnoses/ needs
What is a Care Plan?
Group of categories in Relevant (RMA) that provide caseload organization and quality information for Care Team
What is Caseload Management?
Unable to make contact with a patient at the beginning of the last week of the month, bring case to supervision to find/ re-engage patient
What is Diligent Search?
Manages care for adults with significant behavioral health needs
What is HARP?
Confirm qualifying diagnoses, treatment, medications, identify gaps in care, etc.
What is the Purpose of a Care Conference?
An identified need expressed by the patient/ provider
What is a Problem/ Need?
An overview of a Care Manager's assigned caseload
What is Caseload Overview?
Must be created within 24 hours of patient's discharge
What is a Transitional Care Plan?
Completed during an initial visit with a HARP patient and every year thereafter
What is an Eligibility Assessment?
As part of an initial assessment or reassessment, new diagnoses or medications, at least every 6 months
What is when a Care Conference should take place?
In the course of being addressed or carried out
What is a Goal in Progress?
Provides an HML overview of patients
What is the Billing Support tab?
Takes place 7-10 days after a patient has been discharged
What is a Post-Discharge follow up with provider and Care Conference?
An individualized plan created with patient's goals, preferences and strengths as expressed by the patient
What is a Person-Centered Plan of Care (POC)?
Medical Doctors, Nurses, Behavioral/ Mental Health, MCO, Social Workers, Housing
Who are providers you can Care Conference with?
Actions taken by any member of the Care Team or patient to accomplish goals
What is a Task?
Provides an overview of patients' recent/ past hospitalizations
What is Clinical Event Notifications?
Changes segment to pended status at the beginning of the 1st month of Diligent Search and completes HMLs
Who is the Care Coordinator?
Provide peer/ family support services, pre-vocational services, educational services, crisis respite services, etc.
What is Health and Community Based Services (HCBS)?
When we gather information from patient/ provider, solicit recommendations, document and update the care plan/ agreed goals
What is the Process of a Care Conference?
Makes a Care Plan officially ready for implementation
What is a Care Plan Signature?
Provides a snapshot of Consent, Assessment and Care Plan percentage
What is the Dashboard?
Reviews updated Excel document with Admit Alert response/ feedback prior to submitting to Quality Managers
Who is the Care Coordinator?
Members are eligible for either of these categories
What is Tier 1 or Tier 2?