Section 22-A2506. COMPREHENSIVE CARE MANAGEMENT

 

2506.1Comprehensive Care Management is the assessment and identification of health risks leading to the development and implementation of a care plan that addresses these health risks and the individualized needs of the whole person. Care plan development will be led by qualified practitioners operating within their scope of practice with input from members of the Health Home team and external resources.  

 

2506.2Comprehensive Care Management consists of the:

 

(a)Assessment of health risks and identification of high risk sub groups;

 

(b)Identification of service needs of consumers and construction of a comprehensive care plan addressing physical and behavioral health chronic conditions, current health status, and goals for improvement (see Section 2512 in this chapter);

 

(c)Assignment of different care management roles for a consumer to members of the Health Home Team;

 

(d)Construction of standardized, evidence-based protocols and clinical pathways for mental health, physical health, social, employment, and economic needs;

 

(e) Monitoring of the consumer and population health status and service use;

 

(f) Development and dissemination of reports on satisfaction, health status, cost and quality to guide Health Home service delivery and design; and

 

(g) Development of partnerships with physical health care providers and community-based entities in order to facilitate the sharing of information and timely responses to each consumer’s needs.

 

 

authority

Sections 5113, 5115, 5117 and 5118 of the Department of Behavioral Health Establishment Act of 2013, effective December 24, 2013 (D.C. Law 20-61; D.C. Official Code §§ 7-1141.02, 7-1141-04, 7-1141.06 and 7-1141.07 (2012 Repl.)).

source

Final Rulemaking published at 63 DCR 849 (January 22, 2016).