MedicaidJuly 11, 2023
Transitional Care Services – new requirements
On November, 28 2022, the Department of Health Care Services (DHCS) released All Plan Letter (APL) 22-024, Population Health Management (PHM) Policy Guide, and the associated PHM Policy Guide, outlining a common framework and set of expectations for the PHM Program. Anthem Blue Cross (Anthem) and all its subcontractors and network providers are required to comply with the expectations in the PHM Policy Guide, including Transitional Care Services (TCS).
Starting in 2023, the State requires that managed care plans (MCPs) provide TCS to any member undergoing a care transition. Care transitions are defined as a member transferring from one setting or level of care to another, including, but not limited to: discharges from hospitals, institutions, other acute care facilities, and skilled nursing facilities (SNFs) to home- or community-based settings, Community Supports, post-acute care facilities, or long-term care (LTC) settings.
How Anthem will support Transitional Care Services:
How Anthem will support Transitional Care Services | Description |
Single Point of Contact | Anthem will designate a single point of contact, (care manager) who will assist members throughout care transitions. Providers should expect communication from the assigned care manager. NOTE: the single point of contact will still coordinate care among the discharge facility, the primary care physician (PCP), and/or other treating providers, even if members choose to have limited or no contact with the single point of contact |
CCM or ECM members | For members enrolled Complex Case Management (CCM) or Enhanced Care Management (ECM), the ECM or CCM lead care manager is the designated single point of contact. |
Members not enrolled in ECM/CCM | For members not enrolled in CCM or ECM, the designated single point of contact may be employed by Anthem or by Anthem’s contracted entities (including but not limited to hospitals or primary care provider groups) |
Discharge Risk Assessment & Discharge Planning Documents | While the single point of contact will not perform all activities directly, they will ensure all TCS activities occur, including completion of the discharge risk assessment, discharge planning document, and necessary post-discharge services and follow-ups. |
How Providers can support Transitional Care Services:
How Providers can support Transitional Care Services | Description |
Notification of A/D/T | Notify the PCP and Anthem of members’ admissions/discharges/transfers as soon as possible and no later than 24 hours of an admission/discharge/transfer. |
Add Transitional Care language to the DC planning document | “Transitional Care Services are available for any Anthem member transitioning from one setting or level of care to another. The goal of these services is to provide members support from the time they enter a facility, throughout the stay, and post-discharge, until they’ve been successfully connected to all needed services and supports. Anthem members can call the customer service number on the back of their ID card to be connected with their designated care manager.” |
Discharge Planning Assistance | Partner with Anthem on discharge planning (includes participating in interdisciplinary care conferences, engaging with designated care managers, validating, and sharing member contact information, sharing discharge information, arranging follow-up care with PCP, specialists and/or ancillary providers prior to discharge). |
Discharge Planning Document | Ensure discharge planning document contains all required elements (see below) and is shared with the member, Anthem, and all appropriate parties |
Educate patients about Transitional Care | Educate patients about Transitional Care Services prior to discharge, including what to expect after discharge (for example, follow-up care and continued outreach from care manager). |
Below are DHCS documentation requirements for Transitional Care Services:
Discharge risk assessment requirements:
Required elements in risk assessment |
|
When | Completed prior to discharge |
Who | Completed by discharge facility or designated care manager |
Discharge planning document requirements (completed by discharge facility):
Note: Members cannot receive two different discharge documents from discharging facility and from the designated care manager
Required Elements | Description |
Admitting facility name | Name of admitting hospital/institution/facility |
Available resources | Information regarding available care and resources after discharge |
Barriers | Anticipated barriers to post-discharge plans |
Care Manager and TCS Information | The designated care manager’s name, contact information, and a description of TCS |
Discharge planning participation | Summary of nature and outcome of participation of member and member’s authorized representatives in the discharge planning process |
Name of discharge location | Discharge location recommended by discharging hospital/institution/facility |
Discharge location preferred by and agreed upon by member | |
Pre-admission status | Living arrangements, physical & mental function, SUD needs, social support, DME & other services received prior to admission |
Pre-discharge factors | Member’s medical condition, physical and mental function, financial resources, and social supports at time of discharge |
Services need after discharge | Specific services needed after the member’s discharge |
Recommended pre-discharge counseling | Recommended pre-discharge counseling |
Please note: Except for members enrolled in Medicare Medicaid Plans (MMPs) or other Dual-Eligible Special Needs Plans (D-SNPs) plans, TCS requirements also apply to Anthem members when Anthem is not the primary source of coverage for the triggering service (for example, hospitalization for a Medicare FFS dual-eligible member, or an inpatient psychiatric admission covered by a County Mental Health Plan).
If you have any questions, reach out to your assigned Provider Relationship Management representative.
CABC-CD-028145-23
PUBLICATIONS: August 2023 Provider Newsletter
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