RAP PROCESS

Category 1

100

What change does the CM make to research for a RAP member?

RAP is a complex opportunity. When case identifies with RAP, CM acknowledges the opportunity in an SOE note and incorporates into case plan.

200

When should the CM complete and inpatient confinement call with RAP member?

within 1 day of RAP identification/notification (either IP call or PD call)

300

When a RAP member is discharged from the hospital, what is considered best practice for when post discharge call should be made?

2 calls within 3 calendar days of discharge. (day 1 and day 3)

400

If member is discharged on a Thursday, what day is the best to make that first PD call?

Friday, to avoid going into the weekend without ensuring member has all needs addressed.

500

To avoid readmittance to hospital within 30 days how long is the CM encouraged to keep the member engaged (at minimum)?

30 days

Category 2

100

How frequently should a CM make outreach to the member for the fist 30 days.

At minimum, weekly call should occur 

200

Give me 2 things that a member should understand upon discharge?

1. Member fully understands hospital discharge plan
2. Member has all new medication, understands how/when to take it, and knows whether they should continue other medications they were taking prior to admission
3. Member has a follow-up appointment with a provider, knows when it is, recognizes the importance of that appointment, and has transportation to the appointment
4. Member understands warning signs of a worsening condition and when and where to seek urgent medical care, if needed
5. Members have supplies and support to thrive in the home environment. (Ex. wound care supplies, assistive devices, caregiver assistance, home care services).

300

What are some important items to be sure are documented with our RAP members after PD call?

• If the member received DC instructions and if they were reviewed together
• Does the member have all the medications that were ordered
• Prior to discharge- what instructions did the member receive regarding warning signs or when to call physician
• Have you experienced worsening or change in symptoms
• Follow up appointments set and name/ practice of MD (Physician)

400

How many days should the RAP DGA remain open?

DGA should remain open for 30 days

500

How should the CM complete the DGA if member is readmitted during those 30 days?

Complete as "not met"

Category 3

100

If a member remains out of Acute Care for 30 days post discharge what will the CM mark the DGA as?

If member does NOT have an UNPLANNED readmission during the 30 days, CM closes the DGA as “met” - at the end of the 30 days.

200

When do you close the RAP focus?

RAP Focus can be closed after 30-day RAP monitoring has been completed 

· Exception: RAP Opportunity/Focus is the only complex opportunity within the case that identified member for complex case management. (even if a new complex opportunity is identified after RAP)

· The RAP focus is to be closed upon step down to virtual support or disengagement from care management program.

300

When does the first MD consult need to be completed for RAP members?

Initial MD Collaboration required within 7 calendar days of RAP opportunity identification and documented in CM system notes

400

With a  RAP member (engaged or not) when should the CM outreach the treating provider?

Two attempts within 14 calendar days of RAP opportunity identification

500

What is the TAT for MD notification for all RAP members that have unscheduled readmissions within 30 days of discharge?

 MD collaboration within 7 calendar days 

• Note: MD Collaboration is required for all members with RAP opportunity regardless of engagement status

Category 4

100

What is the TAT for notification to the treating physician for any unscheduled readmissions?

If member unexpectedly readmits while RAP DGA status is open, contact provider by 7 calendar days of readmission

200

When would a member who is identified for RAP be excluded from the RAP process?

Members managed primarily by another department are excluded from RAP process 

· NME 

· Behavioral Health 

· Maternal Health 

· Actively enrolled in Hospice Care 

· Members who permanently reside in a SNF or long-term care facility

** Leave Focus and DGA open for 30 days and document case is managed primarily by another department (be specific).

300

How long does the RAP DGA stay open?

Unless member unexpectedly readmits, the RAP DGA remains open 30 days, whether Case is engaged, UTR, or stepped down.

400

If the RAP member is not engaged, do you need to complete an MD consult?

MD Collaboration is required for all members with RAP opportunity regardless of engagement status

500

If a member is identified for RAP and engaged with the CM, are any referrals mandatory?

Pharmacy referrals are required for all engaged RAP members once medication reconciliation has been completed.

Category 5

100

What assessments are required for a RAP member?

CM Triage

BH needs assessment 

PSS-3 assessment

RAP assessment

200

What is the TAT for CM triage assessment for RAP members?

Initiate CM Triage Assessment within 30 calendar days of member identification, complete within 60 calendar days. 

Note: The completion of the CM Triage assessment indicates completion of the initial assessment period. 

300

What is the TAT for the BH assessment? 

· Best to initiate on engagement call 

 · Complete by 30 calendar days of engagement, by stepdown or whichever is sooner  

· Repeat with condition changes 

400

What is the TAT for the PSS-3 assessment?

· Best to initiate on engagement call  

· Complete by 30 calendar days of engagement or by stepdown whichever is sooner  

· Repeat every 90 calendar days and with condition changes 

500

What is the TAT for the RAP assessment?

RAP assessment (105092000000 Commercial RAP Assessment)

 initiate within 1 calendar day of RAP engagement and complete within 14 calendar days of engagement 

 Repeat every admission while RAP DGA is open