ACO's
ACO is the acronym for
What is Accountable Care Organization?
The enrollee status after the primary care provider has signed off on the care plan
What is engaged?
A meeting scheduled between member and care coordinator after an inpatient or Emergency room visit.
What is a follow up after discharge?
To officially remove an enrollee from the CCP or LTSS CP roster.
What is Disenroll?
This is the time frame that the comprehensive assessment / Service assessment should be completed.
What is 90 days? (CCP wants it in 90 days)
Where would you go to look up ACO contact information?
What/Where is JIVE?
BHCP is the acronym for
What is Behavioral Health Community Partners?
Documentation requested that provides aftercare/follow up appointments, updated medication list, current problem list, diagnosis and more.
What is the discharge summary?
Any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety, or well-being of an enrollee, including but not limited to: fatality, near fatality, calling of law enforcement, medication-related events resulting in significant harm, serious employee misconduct, serious threat of harm, serious injury, or near-miss events.
What is a Critical Incident?
A member has a Substance/Alcohol use disorder diagnosis or the Care coordinator is trying to determine the the members level of substance/Alcohol use. This tool will help determine the level of use.
What is Substance Use Addendum?
Atrius and BIDCO are part of this ACO?
What is TUFTS?
Long-Term Services and Supports
What is LTSS?
This qualifying activity is entered when a care coordinator speaks to someone when the member is in the Emergency Room or at an inpatient level of care.
What is a Care transition note?
A billable encounter with a member that reflects a specific care coordination and or care management service provided by the CP team.
What is Monthly Qualifying Activity?
DAILY DOUBLE!!!
When completing an assessment, if person declines to answer any section or is unable to be assessed for any reason, these sections should be noted in the.
What is the Narrative Summary section?
Community Care Cooperative is also known as
What is C3?
A face to face care coordination qualifying activity
What is Direct Care?
Nurse follows up with primary care provider to verify current medication's after a discharge.
What is a medication reconciliation?
Hard to reach, decline participation, deceased, graduation, moved out of the geographical area, disengaged, and eligibility loss.
What are reasons for disenrollment?
What two signatures are required for a care plan to be complete?
What/who are the primary care provider and the enrollee?
BMC has recently changed it's name to this
What is WellSense Health Plan?
Enrollee becomes age 65, obtains Medicare A&B, lose MassHealth or lose their ACO.
What is ineligible for BHCP or services?
If the follow up after discharge was completed via phone for an ED discharge, the care coordinator must complete Follow up after discharge form accompanied by.
What is a care transition qualifying activity note?
Any expression of dissatisfaction by an Assigned or Engaged Enrollee (or Authorized Representative, if applicable) about any action or inaction by CCP.
What is Grievance?
When you begin a new CHA (BH), Social Services Assessment (LTSS), PCTP or LTSS Care Plan in eHana, the 3rd field down is labeled “Date” and autofill's with the date you started creating the document.
Care coordinators must adjust the date at the top of the document to reflect what date.
What is the date the document is finalized?