TOC
What does “TOC” stand for in care management?
Transition of Care
What two insurances do DSNP members have?
Medicare and Medicaid
What does ICT stand for?
Interdisciplinary Care Team
What is a “non-responder”?
Member unreachable after required outreach attempts
What tool documents all Care Management activity?
TruCare
Within how many days must a member be outreached post-discharge?
Within 3 days of discharge notification
What triggers a Care Plan Update letter?
Adding new Problems, Goals & Actions (PGAs) in the Care Plan
Who is always included on the ICT?
Member, Care Manager, Primary Care Provider
How many outreach attempts are required before closure?
Two calls and one letter
What method confirms member understanding?
Teach-back method
What is the main purpose of the TOC Assessment?
To reduce barriers and prevent readmissions after hospitalization
What triggers a Non-Responder task?
Failure to complete Initial or Annual HRA
What is the ICT meeting’s main purpose?
Coordinate care and review member’s Individualized Care Plan (ICP)
What letter must be sent after the first unsuccessful attempt?
Generic Outreach Letter
What tool must be completed after an ER visit?
Emergency Room Screening Tool in TruCare
What auto-task is triggered when “No appointment scheduled” is selected?
Follow up with member to set up PCP appointment
What happens when a DSNP member opts out of care management?
Opt-Out letter is sent; Care Plan PGAs are closed as “member unwilling to participate
How often should high-risk members receive an ICT review?
At least annually or as needed based on risk
What note tab can only be completed with the member?
Mood & Well-Being tab
Which document authorizes a designated representative to file an appeal or grievance on behalf of the member?
An Appointment of Representative (AOR) Form
Which tab captures the root cause of hospitalization in the member’s own words?
Post Discharge Member Engagement tab
When must an Initial HRA be completed?
Within 90 days of enrollment
What should be done if a new HRA is completed?
Restart the ICT process and update ICP
What should CMs do if a new HRA appears during Non-Responder review?
Complete ICT process and complete Non-Responder task
What’s the difference between ER and Urgent Care for breathing difficulty?
ER for severe distress; Urgent Care for mild asthma flare