HomeMy WebLinkAboutMINUTES - 11281995 - D3 Contra
TO: BOARD OF SUPERVISORS (CN
FROM: Mark Finucane, Health Services Director Coirty
DATE: November 16, 1995
SUBJECT: PUBLIC HEALTH MEMORANDUM OF UNDERSTANDING
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
I. RECOMMENDATION
1. APPROVE the Memorandum of Understanding(MOU)between Contra Costa County Public Health&CCHP that delineates
areas of collaboration between Public Health and the Medi-Cal managed care Local Initiative(Attachment A).
2. AUTHORIZE the Health Services Director or his designee to use the MOU provisions as the model for any agreements to be
reached with the commercial Medi-Cal plan in Contra Costa County.
3. AUTHORIZE that the Health Services Director or his designee convey the approved MOU to the State Department of Health
Services as part of the Detailed Design Application.
4. ESTABLISH the MOU as the Board of Supervisors'policy in Contra Costa County on the relationships between all managed
care plans and County public health services.
II. FINANCIAL IMPACT
The MOU helps ensure that managed care practices help support County public health services.
III. BACKGROUND AND JUSTIFICATION
Under the State of California's plan for expanding Medi-Cal managed care(the two plan model)the managed care plans are to enter
into an agreement with the local health department concerning specified public health services. This agreement is to cover scope and
responsibilities of both parties,billing and reimbursements, reporting responsibilities,and medical record management to ensure
coordinated health care services. The specified public health services include Family Planning Services, STD Services,Confidential
HIV Testing, Immunizations,California Children's Services(CCS),Maternal and Child Health(MCH),Child Health and Disability
Prevention(CHDP)Program,Tuberculosis Direct Observed Therapy,Women,Infants&Children(WIC)Supplemental Food Pro-
grkn,and Population Based Prevention Programs.
CCHP,as the Medi-Cal Local Initiative, is to submit this agreement to the State Department of Health Services as part of its detailed
design application for Medi-Cal Managed Care. The commercial Medi-Cal plan is required to negotiate with the local health depart-
ment and to enter an agreement to coordinate services. This MOU,which has been signed by the Executive Director of CCHP and the
Public Health Division Director,serves as the model for the commercial plan agreement. It can also be used as the official Board of
Supervisors policy as to the desired relationships between all managed care plans and County public health services.
a
This MOU was reviewed and approved-previously by the now sunseted Medi-Cal Advisory Planning Commission and HMO Advi-
sory Board,and on November 15, 1995 was reviewed and approved by the Managed Care Commission,which recommended that the
Board of Supervisors approve the document and convey it to the State Department of Health Services.
Attachment- Public Health MOU
CONTINUED ON ATTACHMENT: YES SIGNATURE: 4—�
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE _OTHER
SIGNATURE(S):
ACTION OF BOARD ON November 28, 1995 APPROVED AS RECOMMENDED X _ OTHER
VOTE OF SUPERVISORS
g UNANIMOUS(ABSENT none ) I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT
AYES: NOES: COPY OF AN ACTION TAKEN AND ENTERED ON THE
ABSENT: ABSTAIN: MINUTES OF THE BOARD OF SUPERVISORS ON THE
DATE SHOWN.
cc: Health Services Administration
Contra Costa Health Plan ATTESTED November 28, 1996
Public Health Administration PHIL BATCHELOR,CLERK OF THE BOARD OF
SUPERV16ORS AND COUNTY ADMINISTRATOR
BY _,DEPUTY
k\boardord.pm4
MEMORANDUM OF UNDERSTANDING
between
CONTRA COSTA PUBLIC HEALTH
(Local Health Department)
and
CONTRA COSTA HEALTH PLAN
(Local Initiative)
Wendel Brunner,M.D. f,1ihS.Camhi
Director,Public Health Executive Director,CCHP
Date Date
November 1995
MEMORANDUM OF UNDERSTANDING
Contra Costa County Public Health&Contra Costa Health Plan Local Initiative
TABLE OF CONTENTS
Page
Introduction 1
Collaborative ProgramResponsibWties 2
A. Community Health Promotion&Outreach 3
B. CHDP 4
C. Local Maternal&Child Health(MCH)Program 7
D. Well Baby 10
E. Immunization Services 11
F. TB Services 12
G. Sexually Transmitted Disease(STD)Services is
H. Confidential HTV Testing 17
I. Family Planning Service 18
J. Nutrition Services 19
K. Prevention-Chronic Disease,Intentional and
Unintentional Injury Prevention 20
L. California Children's Services 21
klmouconts.pm4
MEMORANDUM OFUNDERSTANDING
between
Contra Costa County Public Health
and
Contra Costa Health Plan Local Initiative
INTRODUCTION
Contra Costa County Public Health and the Contra Costa Health Plan Local Initiative have complementary
objectives to protect and promote the health of the general population. Public Health's role is to promote the
health of the community as a whole,through population-based health assessments and population and individual
interventions. Managed care provides an opportunity to link community-based Public Health with medical care
of high risk populations. It is understood that public health is traditionally concerned with the community's
collective health.
The Local Initiative will be providing and arranging health care services for the community's Medi-Cal popula-
tion and,thus,is also concerned with the community's health,especially as it relates to the most vulnerable
populations. With a common interest in the community's health,Contra Costa County Public Health and the
Local Initiative seek to become working partners in preventing disease,prolonging life,and promoting mental
and physical health through organized community efforts.The intent of this MOU is to ensure that managed
care competition practices do not inadvertently or deliberately endanger vital public health services. This
memorandum of understanding delineates areas of collaboration between public health and the Local Initiative
in Contra Costa County.
I. Contra Costa County Public Health Responsibilities
Contra Costa County Public Health will maintain its traditional core functions. Population based public
health services are to remain a separate and distinct function of government. Among the core functions
that are related to the Local Initiative are:
Health data collection and analysis including vital statistics,community health assessment,and disease
surveillance,case finding and reporting functions.Additionally,the systematic analysis,from an epide-
miological perspective,of clinical outcomes and utilization data provided by request,from the Local
Initiative.
Investieation and control of adverse public health conditions including planning for and oversight ofa
comprehensive emergency medical services program which includes an emergency response system
and Board of Supervisors designated trauma center; population-based chronic disease prevention;
injury/violence prevention and control;disease outbreak management;prevention and management of
adverse outcomes in maternal and child health;prevention of disability;and control of other threats to
individual health status.The Local Initiative will support these community-wide efforts.
Public information and education programs including programs to reduce risks to health such as;to-
bacco,alcohol abuse,sexually transmitted diseases,poor diet,physical inactivity and low immunization
levels and to promote healthy lifestyles and beneficial health behaviors such as prenatal care,from an
individual as well as public policy level.The Local Initiative will collaborate in these program initiatives.
Leadership,policy development,and administration including needs assessment,setting ofpublic health
standards and policies,and coalition building.As appropriate,the Local Initiative will be asked to partici-
pate in policy formulation.
KTHMOU.PM5
1
Contra Costa County Public Health will network with the Local Initiative by:
Facilitating necessary referrals and providing the Local Initiative with current information on local -
agencies and organizations,their services and programs for low-income persons,and eligibility
requirements(e.g.,information and resources booklet).
Establishing a system for coordinating care with the Local Initiative.Where feasible,Contra Costa
County Pubic Health will contact the Local Initiative prior to the provision of services to obtain
medical information to avoid duplication.Public Health will provide the Local Initiative the medical
records sufficient to meet its case management responsibilities.
Making good faith efforts to establish timely and accurate billing reimbursement and record
management systems with the Local Initiative.
II. Local Initiative Resnonsibilities
The Local Initiative will:
Ensure the planned provision of preventive,primary care and early interventions to its enrolled popula-
tion.
Ensure organized and comprehensive managed care systems that eliminate fragmentation in case
management and health care delivery and that improve quality of life.
Refer Local Initiative beneficiaries, in compliance with state and federal law and otherwise when
appropriate,to local agencies and organizations including public health providing services and programs
for low-income persons.
Comply with all State and local requirements for reporting diseases and conditions.Disseminate to its
provider network the information provided by Public Health regarding local community resources.
Make good faith efforts to establish timely and accurate billinp-/reimbursement systems with Public
Health services.
Dedicate a portion of any surplus from its Medi-Cal program to support community-based public health
prevention and outreach programs.
Comply with requirements of the County's emergency response and trauma care system which provide
immediate access to life saving interventions for illness including cardiovascular disease and for injuries
resulting from accidents and/or violence. Use the County's officially designated trauma center for those
members who require these services and reimburse the center at a payment level which adequately
supports the costs of the trauma center services subject to County Emergency Medical Services over-
sight.
III. Coll aborativeProgramResponsibiIities
Contra Costa Public Health and the Local Initiative agree to collaborate on Community Health Promo-
tions&Outreach,CHDP,Local Maternal &Child Health(MCH),Well Baby,Immunization Services,
TB Services,Sexually Transmitted Disease(STD)Services,Confidential HIV Testing,Family Planning
Services,Nutrition Services,Chronic Disease,Intentional&Unintentional Injury Prevention,and
California Children's Services.
Note: Italized Local Initiative activities are in County Specific Criteria
2
A. Community Health Promotion&Outreach
CATEGORY PUBLIC HEALTH LOCAL TNITIATNE
Community-Wide In consultation with community groups, Plan agrees to reinvest a portion of
Programs including PEHAB,annually establish any surplus from its Medi-Cal
public health priorities. program into community health
programs operating in the County.
Work with Plan and PEHAB in
designing and carrying out prevention Plan agrees to work with Public
programs. Health in designing and carrying out
prevention programs.
As part of provider education,
clarifies and emphasizes prevention
services as a benefit. Makes providers
aware of social support services,
encourages provider to make
referrals and do follow-up.
Community Outreach Work collaboratively with Plan to Plan agrees to annually dedicate no
Advertising develop community outreach less than 5%of previous years total
advertising to include minority print, advertising budget(excluding staff
radio and TV advertising media. costs)to community outreach in
Contra Costa County advertising
collaboratively planned with LHD.
Community Health Analyze community health data for Provide to LHD relevant health
Indicators developing profiles,planning and data and statistics including HEDIS
prevention activities. data,morbidity,mortality and
disease incidence data.
Work with Public Health to solve
identified community-wide health
problems such as teen pregnancy,
infant mortality,communicable
diseases.
3
B. CHDP
77
CATEGORY LOCAL CHDP PROGRAM LOCAL INITIATIVE
Liaison Appoint a liaison person to coordinate Appoint a liaison person to coordinate
activities with the Local Initiative and activities with CHDP and to notify
to notify CHDP staff of their roles and staff and providers of their CHDP
responsibilities responsibilities.
CIient Outreach 1.Outreach to potential Medi-Cat 1.Inform Local Initiative members of
eligibles. their CHDP entitlement.
2.Coordinate(with Local Initiative) 2.Provide local CHDP office with a
outreach to members not using; list of plan providers.
preventive health services.
3.Inform Local Initiative providers
of 200%funding mechanism for those
Medi-Cal eligibles who are dropped
from the Plan or who lose eligibility.
Initial CHDP Referral from 1.Refer member to nearest med ical
Eligibility(enrollee requests clinic site or public health site,.
CHDP servicesat eligibility 2. Upon request,schedule appointments
3.Notify patients of date and gime
of appointments.
4.Verify appointment status(kept/
not kept)for applicable clients.
Appointment Scheduling 1.Handle client request for assistance 1.Primary responsibility for sched-
& Transportation Assistance with appointment scheduling,,dental uling patient medical appointments.
referrals and transportation information.. 2.Provide CHDP with copy ofPM160
4
CATEGORY LOCAL CHDP;PROGRAM LQCAI IN�TTATIVE
Tracking&Follow-up. 1.Provide consultation to Plan providers 1.Responsible for primary care case
and assist in tracking hard to reach clients,_ management,coordination,medical
e.g.,clients lost to Managed Care prov- referrals and continuity of care.
ider;members who lose Medi-Cal eligi- 2.Refer children who have lost Medi-
bility and Plan benefits and still need Cal eligibility and Plan benefits and
treatment;members with serious problems still require treatment to the CHDP
who do not maintain treatment plan. program.
2.Carry out required periodicity notifi- 3.Refer potentially eligible members
cation to plan members upon receipt of to community resources such as CCS,
periodicity labels from state CMS and WIC,Head Start,Regional Center,
follow up on missed appointments. Mental Health Services and Dental
3.Report results of case follow-ups to Care.
primary care provider as requested. 4.Remind members seen for episodic
4.Assistance and technical consultation care of need for appropriate periodic
to Local Initiative in making referrals to wellnessexam.
appropriate community resources and 5.Refer children 3 years and older to
agencies. dentist for initial appointment.
5.Refer children 3 years and older to 6.Baby tracking
dentist for initial appraisal.
Health Education 1.Perform community-wide education 1.Plan members will provide anti-
about child health issues,including CHDP cipatory guidance according to CHDP
services. guidelines.
2.Make health education resources avail- 2.Coordinate prevention activities
able to Local Initiative that support the targeted to children and teens with
provision of anticipatory guidance in the CHDPstafl:
CHDP exam(i.e.,brochures,videos or
training on a variety of topics such as
nutrition,injury prevention,lead screening
and anti-tobacco information).
ProviderNetwork 1.Act as a consultant to the Local Initia- 1.Primary responsibility forprovider
tive regarding CHDP policies and guide- recruitment and retention services.
lines. 2.Provide training to providers on
2.Assist Local Initiative in provider CHDP standards,in collaboration with
training on CHDP standards. CHDPstaff.
3.Distribute all CHDP provider notices 3.Disseminate CHDP provider
to Local Initiative. notices to plan providers.
Data Collection& 1.Use yellow copies to perform appro- 1.Plan providers complete PHP/
Reporting priate follow-up and data analysis. PM 160 and forward to EDS unit on
a monthly basis.
2.Plan providers forward yellow
community copy to CHDP on a flow
basis.
5
CATEGORY LOCAL'CHDP PROGRAM LOCAL INITIATIVE
Quality Assurance 1.Provide consultation to Plan regarding 1.Ensure provider compliance with
EPSDT mandates. federal EPSDT mandates,establishing
2.Review and analyze data available standards and policies to implement
throughPM160. mandates and determine provider
3.When a problem provider is identified qualifications.
based on member complaints or other 2.Plan QA Coordinator collects
information,CHDP alerts Local Initiative needed data indicators available
QA Coordinator to initiate appropriate through Plan resources.
corrective action. 3.Develop correction action plan when
4.Assist as requested in implementation standards are not met.
of corrective action plan. 4.Implement corrective action plan.
Follow-up on Codes 2,4 1.EPSDT PHN reviews all PM 160s with 1.Note codes on PM 160.
&5 follow-up codes 2,4 and 5. 2.Handle transportation/scheduling
2.Provide Public Health case management problems.
(2-recheck on exam, regarding follow up codes.
4-diagnosis pending,return 3. Refer transportation/scheduling
visit scheduled. problems to Local Initiative.
5-referred to another
provider.
Disenrollee Information Provide targeted outreach to disenrol lees. 1.Make CHDP information pamphlet/
procedure available on monthly basis
via a letter of instruction.
2.Provide CHDP with monthly list
of disenrollees.
Coordination of Activities 1.CHDP liaison arranges for regular 1.Plan liaison attend meetings.
scheduled coordination meetings. 2.Participates in review of policy
2.Review and update Local Initiative issues.
re:EPSDT policy changes orprogrammatic 3. Keeps providers apprised of prog-
changes rammatic changes.
3.Responsible for keeping Local Initiative 4.Works with CHDP to assure and
liaison apprised of local CHDP capacity maintain open lines ofcommunication
to maintain an agreed upon Memorandum re:client service and capacity building.
of Understanding.
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C. Local Maternal & Child Health(MCH)Program
CATEGORY LOCAL:MCH;PROGRAM; LOCAL INITIATIVE
Liaison Responsible for appointing a liaison person Responsible for appointing a liaison
to coordinate activities with the Local person to coordinate activities with
Initiative and to notify MCH staff oftheir MCH and to notify staff and providers
role and responsibilities of their responsibilities.
Outreach Responsible for outreach to pregnant Responsible for informing plan
women and assisting them to get into members about all available services
care. including importance of early prenatal
care.
Appointment Schedule& Assist pregnant women with scheduling Responsible for scheduling timely
Transportation Assistance and securing transportation assistance. patient appointments.
Education 1. Responsible for community-wide educa- 1.Contract with MCH forprovider and
tion on MCH issues including perinatal, enrollee education regarding perinatal
child health and family psychosocial, issues,women's health,family health,
health education and nutritional issues. SIDS,etc.
2.Assist plan in identifying invisible 2.Provide staff training on reducing
barriers to care based on cultural and invisible barriers.
language differences.Conduct training
and consultation to address cultural 3.Provide culturally competent staff
competency concerns. to serve the multi-cultural population
enrolled in the Plan.
Case Management 1.Assist Plan in tracking hard to reach 1.Responsible for primary care case
clients;pregnant women who lose management,coordination ofreferrals
Medi-Cal eligibility and plan benefits,etc. and continuity of care.
2.Provide technical assistance and consul- 2.Responsible for following up on
tation to Plan on available community missed appointments according to
resources and linkages,with special approved protocol.
attention to perinatal and family health
issues and resources. 3.Assess and refer pregnant women
when appropriate to available comm-
unity resources including,but not
limited to:Genetic screening and
counseling,child care,public health
nursing services,emergency food and
shelter,domestic violence shelters or
assistance,family planning,pediatric
care,child safety seat programs,
lactation services,CDAPP,AFLP/Cal
Leam,BIH,SIDS Program,WIC,etc.
7
CATEGORY LOCALMCHPRO'GRAM 'LOCAL INITIATIVE
Credentialing Prov ide in formation to Plan regard in&CPSP Responsible for implementing a
standards and approve Plan's prenatal prenatal care program approved by the
care program. LHD as consistent with CPSP
standards.
Planning&Referral of 1.Assist Plan in identifying unmet family 1.Responsible for identifying service
Services health and service needs. needs or gaps and developing a plan
for addressing them,e.g.,language,
literacy,cultural competency.
2.Assist Plan in identifying community 2.Assess and refer family members
resources and developing methods for when appropriate to counseling,
assessing and referring family members in education and support resources.
need of assistance.
3.Responsible for developing
3.Assist Plan in developing protocols procedures for enrollees who lose
for insuring continuity of care for Medi-Cal eligibility and making
pregnant women. appropriate referrals force-establishing
eligibility and continued care.
Data Collection& 1.Local MCH is responsible for on-going 1.Participate in infant morbidity and
Quality Assurance review of MCH health status indicators mortality review processes and comm-
such as infant morbidity and mortality. unity-wide corrective actions including
the FIMR(Fetal/Infant Mortality
Review)process.
2.Assist the state in follow-up of correc- 2.Ensure services are provided in
ective action plans identified by audits. compliance with state approved
prenatal protocols.
3.Provide consultation to the Plan
egarding CPSP requirements;initial 3.Collect needed data available
assessments and interview protocols through Plan resources and
to be followed. provide on request to Public Health.
4.Develop a corrective action plan
when standards are not met.
Prenatal Access 1.Work closely with Plan and community 1.Participate with local MCH liaison
groups regarding access of care issues for (and community groups)to address
eligible and ineligible pregnamtwomen. access of care issues of eligible
pregnant women.
2.Inform Plan of funding mechanisms 2.Ensure that pregnant women will be
for those Medi-Cal eligibles who lose assigned to appropriate obstetric care
eligibility. providers.
8
CATE.G0 VH., CALMCH PROGRAM LOCALINITIATIVE
ProviderNetwork 1.Provide technical assistance on:educa- 1.Primary responsibility for provider
tional needs of staff for optimal operation recruitment and maintenance of
of the CPSP program;relevance of services.
protocols and assessment tools to present
practice;up-to-date referral resources, 2.Ensure that all obstetric care
develop plans to resolve any identified providers,upon'entry to the Local
needs and/or deficiencies and provide Initiative,receive orientation on State
ongoing technical assistance as indicated. approved prenatal care standards
(unless they are already approved
2.Make perinatal health education CPSPproviders.)
resources available to providers and
support the provision of CPSP compre- 3.Disseminate CPSP provider infor-
hensive perinatal care. mation to plan providers.
3.Distribute all CPSP provider program 4.Inform providers of available
information to the Plan. community education services(such
as Council for Perinatal Health,CPSP,
4.Organize,conduct and/or participate in Roundtables,etc.)and encourage
information sharing activities(e.g.,round- participation.
tables,newsletters,etc.)for Plan providers.
9
D. Well Baby
CATEGORY "OCALWELL BABY PROGRAM LOCAL INITIATIVE
Immunizations Provide immunizations and well baby Contract with LHD to provide
exams to Local Initiative members. immunizations and well baby exams.
Conduct immunization clinics and well Provide LHD with updated
baby clinics. information on the status of member
immunizations.
Provide immunization records to the
Local Initiative Reimburse LHD forimmunizations.
10
E. Immunization Services
CATEGORY LOCAL EALTH DEPT LOCAL;INITIATIVE
Education; Keep Local Initiative apprised of current Plan will provide health education
immunization recommendations and any information to all new parents and
changes in those recommendations. others with small children to ensure
theirtimely follow-up with children.
Reporting Analyze immunization data from Local Plan will,upon request,provide
Initiative and provide this analysis to the updated information onthe status of
Local Initiative. members'immunizations.
Providing Childhood Approve Local Initiatives protocol to Plan will develop protocols to ensure
Immunizations ensure access to immunizations. members'access to timely immuniza-
tions and submit draft protocols to the
Hold immunization clinicsand,foran LHDforapproval.
administrative fee of not greater than$7
per childhood vaccine will provide Plan will provide timely immunizations
immunizations at public clinics to Local to members,maintaining up-to-date
Initiative members. immunization records,following up
on members who received immuniza-
tions from the LHD and will ensure
reimbursement for the administrative
fee ofLHD-administered immuniza-
tions for members.
Plan will maintain childhood immuni-
zation records in individual patient
charts.Information must include
vaccine given,dates given.This
information will be made available for
record review on request of LHD.
Providing Adult Immuniza- LHD wi I I provide i nformati on to the Plan wil I provide adult immunizations
tions on an as-needed basis Local Initiative on recommendations for as recommended by the LHD and
adult immunizations including but not ACIP guidelines.
limited to recommended immunizations in
advance of travel out of the county,and Plan will provide information on local
recommendations concerning members in resources for recommended travel
specific occupational settings. immunizations.
Plan will report as requested to the
LHD on adult immunizations
provided.
Special Clinics LHD will report to the Local Initiative The Plan and its medical providers will
on the status of immunization compliance submit to the LHD protocols for
within the Plan. corrective action if childhood
immunization rates forDPT,MMRor
polio fall below 90%,according to recom
mended guidelines for childhood
immunizations.
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F. TB Services
CATEGQR.Y PUBLIC HEALTH LOCAL INITIATIVE
Reporting of persons with Responsible for informing providers on Responsible for reporting to LHD
known or suspected TB the reporting procedures and require- (Local Health Department)within
ments. seven days of identification of
case of active or suspected TB.
These reports will include:
Patient demographics:
name,age,address and home
phone,date of birth,gender,
ethnicity,marital status.
Locating information:
(employer,work address and
phone number),contacts.
Physician information:
physician and his/her phone
number and address.
Treatment information:
date of onset,symptoms,risk
factors,physical findings,chest
x-ray findings,bacteriology
results and dates,PPD induration
and interpretation,medications,
(names,dosages and dates initiated)
compliance history,and any other
diagnoses.
Referral and Follow-up Attempts to locate lost-to-follow-up Responsible for following up on
patients if plan is unable to do so after missed appointments per approved
reasonable attempt per plan protocol. protocol and notifying LHD of
patients lost to medical follow-up.
Provide patient and contact follow-up
investigation as needed. Reports to LHD patients who are
non-adherent to treatment regimen
Available for medical consultation including missed appointments.
regarding the management of patients
with all forms of TB infection or disease. '
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CATEGORY PUBLIC HEALTH;' LOCAL I1vITIATIYE
Directly Observed Therapy Provide directly observed therapy upon Refer TB patients for directly
(D.O.T.) referral by Plan. observed therapy to LHD when
criteria for D.O.T.are met.
D.O.T.should be considered for all
patients at risk for non=compliance.These
include those with a history of alcohol or
drug abuse, adolescents, homeless non-
adherence in the past,history of previous
TB treatment,history of being in a
correctional facility,major psychiatric
disorder,poor compliance during initial
therapy,slow sputum conversion or slow
clinical improvement,adverse reaction to.
TB medications,too uninformed to self-
manage and children needing therapy whose
parents are in any of these categories.
Contact Investigation Responsible for conducting contact invest- Cooperate with LHD in conducting
igation upon receipt of Plan's report of a contact investigation of a Plan TB
TB case, suspects, recent converters and patient.
reactors under seven years old.
TB Education Responsible forcommunity-wide TB Responsible for educating its providers
education. and members(including all known
cases and suspected contacts) regardin
TB control and the treatment strategies.
When surveillance information demon-
strates a particular problem in the
region or city of the County in which
the Managed Care Program operates,
the Managed Care Provider will
develop and implement a plan to
provide TB information to all members
in consultation with LHD.
Discharge Information Responsible for reviewing discharge Persons diagnosed with active TB may
treatment plans within the next business be discharged from a health facility
day following receipt of report. only after a written treatment plan is
approved by the LHD,unless the
patient is transferring to a general acute
care hospital when the transfer is due
to an immediate need for the higher
level of care nor to any transfer from
any health facility to a correctional
institution. Treatment plans must
include all pertinent and updated
information required by the LHD not,
previously reported on initial or sub-
sequent reports and shall specifically
include verified patient address,the
name of the medical provider who has
specifically agreed to provide medical
care,clinical information used to assess
the current infectious state,and any
other information required by the LHD.
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CATEGORY PUBLIC HEALTH LOCAL,INITIATIVE
Data Collection Responsible for collecting data on all Responsible for ensuring that providers
reported TB cases in the community. maintain up-to-date information on all
clinically active and suspected TB
cases within the Plan's enrolled
population.
Provide quarterly reports to the LHD
on the current status of all reported TB
cases and suspects.
Reports should include those who have
completed treatment,those currently
in treatment,those lost to follow-up
or dropped from care and referred
elsewhere.
Cooperate with LHD by providing
data as requested.
14
i
G. Sexually Transmitted Disease(STD)Services
CATEGORY PUBLIC HEALTH LOCAL INITIATIVE
Education Approve protocol submitted by the Local Plan will submit a protocol for approval
Initiative to ensure risk reduction informa- to the LHD detailing methods to
tion to high risk adolescent and adult Local assure that all high risk adolescents and
Initiative members. adults will receive language-appropriate
information on methods to reduce their
Provide community outreach in commun- risks of acquiring sexually transmitted
ities at risk for STDs. disease and to include distribution of
sample condoms.
When surveillance information demon-
strates a particular problem in the
region or city of the County in which
the Plan operates,the Local Initiative
will develop and implement a plan to
provide STD risk reduction information
to all members in consultation with
LHD.
Reporting The LHD is responsible for informing Plan ensures that all medical care
providers on the reporting procedures and providers will report to the LHD
requirements. within seven days of identification of
the following sexually transmitted
LHD will submit reports to the Local diseases: syphilis, gonorrhea,
Initiative on the status of STD control in chlamydia,herpes simplex,chancroid,
the Local Initiative and in the city(ies)in Trichomoniasis,human papilloma
which the Local Initiative operates. virus,non-gonococcal urethritis,
lymphogranuloma venereum and
granuloma inguinale.
Information to report to the LHD
includes the following:
Patient demographics:name,age,
address and home phone,date of birth,
gender,ethnicity,marital status.
Locating Information:employer,work
address and phone number.
Disease Information:disease diagnosed,
date of onset,symptoms,laboratory
results,and medications prescribed.
15
CATEGORY PUBLIC HEALTH LO:CAL'INITIATIVE
Contact Investigation LHD is responsible for conducting Plan will provide names of contacts or
contact investigations onpatients with the will cooperate with LHD in
following sexually transmitted diseases: conducting contact investigations of a
syphilis,gonorrhea,chlamydia,LGV and Plan STD patient.
chancroid.LHD will contact patients with
confirmed cases of the above diseases to
obtain information on sexual contacts and
to assure treatment of contacts.
Providing Treatment In order to maximize the opportunity of Plan will provide access to STD
treating the infection and control the services without prior authorization to
spread of disease,Local Initiative members all members both within and outside
may access STD services through STD its provider network.The reimburse-
clinics ofLHD as well as family planning ment of out of plan STD services is
providers qualified and monitored by the limited to one office visit per disease
LHD. episode for the purposes of:
(1)diagnosis and treatment of vaginal
discharge and urethral disease,
(2)those STDs that are amenable to
immediate diagnosis and treatment
(including syphilis,gonorrhea,
chlamydia,herpes simplex,chancroid,
Trichomoniasis,human papilloma
virus,non-gonococcal urethritis,
lymphogranuloma venereum,and
granuloma inguinale and(3)evalua-
tion and initiation of treatment of
Pelvic Inflammatory Disease(PID).
The Plan will provide follow-up care.
The Plan will reimburse STD
providers at the Medi-Cal fee-for-
service(FFS)rate,unless otherwise
negotiated,and the Plan will provide
reimbursement only if STD treatment
providers provide treatment records to
the Plan.
At the patient's request,patient
identifiers can be withheld from the
treatment record. Plan has a right to
do a confidential audit of treatment
records and billing practices.
16
H. Confidential HIV Testing
h
CATEGORY PUBLIC HEALTH ! LOCAL INITIAfiIVE
Provide confidential HIV testing and Contract with Public Health to provide
counseling services for Local Initiative confidential HIV testing and counseling
members. services.
Make reasonable efforts,consistent with
current law and regulations,to report
confidential test reports to the Local
Initiative.
17
I. Family Planning Service
CATEGORY PUBLIC HEALTH LOCAL INITIATIVE
Provide the full array of family
planning services covered under the
Local Initiative without prior
authorization.
Inform enrollees of their right to
access family planning services in
writing and provide referrals to
qualified family planning providers,
when requested.
Provide comprehensive family planning ReimburseLHDandotherqualified
information and clinical services family planning providers for services
including: to temporarily or permanently prevent
or delay pregnancy at the Medi-Cal
fee for service rate unless otherwise
mutually agreed upon.
(1)Health education and counseling. (1)Health education and counseling
necessary to make informed choices
and understand contraceptive methods.
(2)Limited history and physical exam. (2)Limited history and physical exam.
Comprehensive physicals are the
responsibility of the Plan.
(3)Lab tests if medically indicated as (3)Lab tests if medically indicated as
part of the decision-making process. part of the decision-making process
for choice of contraceptive methods.
The Plan will not reimburse CHDP
for pap smears if the Plan has
provided pap smears to meet the
USPSTF guidelines.
(4)Diagnosis and treatment of STDs (4)Diagnosis and treatment of STDs
ifinedically indicated. ifinedically indicated.
(5)Screening,testing and counseling (5)Screening,testing and counseling
of at-risk individuals for HIV and of at-risk individuals for HIV and
referral for treatment. referral for treatment.
(6)Follow-up care forcomplications (6)Follow-up care forcomplications
associated with contraceptive methods. associated with contraceptive
methods issued by the family
planning provider.
(7)Provision of contraceptive pills, (7)Provision of contraceptive pills,
devices, supplies. devices, supplies.
(8)Tubal ligation. (8)Tubal ligation.
(9)Vasectomies. (9)Vasectomies.
(10)Pregnancy testing and counseling. (10)Pregnancy testing and counseling.
18
J. Nutrition Service
CATEGORY ' PUBLIC HEALTH LOCAL INITIATIyE
Nutrition Services P.H.will assist the Plan with the Plan will provide medical nutrition
development andmonitoring of specific assessment,medical nutrition therapy
guidelines for nutrition services and and clinical preventive nutrition
programs. education and counseling to
enrollees.
When medically necessary,the MD
or FNP will provide these nutrition
services directly or upon referral with
prescription to Registered Dietitians
or other licensed health professionals
who have medical nutrition therapy as
part of their scope of practice as
defined in the California State Business
& Professions code.
Services will be provided in a
clinically appropriate timeframe.
Mechanisms for referral to these
services will be in place.
Plan will educate enrollees and medical
providers about availability of these
services.
Plan agrees to offer comprehensive
nutrition education programs.
19
K. Prevention-Chronic Disease,Intentional and Unintentional Injury Prevention
CATEGORY PUBLIC HEALTH LOCAL INITIATIVE
Provider Training Develop protocols and risk assessments, Provide access to Public Health to
and other tools and facilitate training of train providers;collaborate with Public
providers on their use. Health in evaluating effectiveness of
protocols and other tools.
Work with primary care providers to
utilize risk assessments for appro-
priate patient interventions.
Education Collaborate with Local Initiative to Provide input regarding patient
develop patient education models;provide information needs;implement appro-
outreach regarding community resources. priate patient education models;
collaborate with outreach efforts.
Intervention Collaborate with Plan in the development Implement appropriate interventions.
and implementation ofprimary clinical
prevention interventions.
20
IF L. California Children's Services(CCS)
CATEGORY CCS LOCAL INITIATIVE
Client Outreach Provide technical assistance and consult- Inform members ofavailability of
ation to Plan and providers,includes CCS benefits.
assistance in identification of CCS eligible
conditions.
Maintain liaison with Plan providers, Assure providers and Plan staff are
includes education to clients and Plan. awareofCCSeligibilityand Plan's
responsibility to referall eligible
cases to CCS for case management of
the CCS eligible condition(s).
Client Assistance Assist client in obtaining care for CCS Primary responsibility to provide
eligible condition;i.e.appointment medical care for non-CCS condition.
assistance as needed.
Educate client family of services to be
provided through CCS and how system
works.
Referral&Case Provide special medical needs case Responsible for primary care case
Management management in such,coordinate and management.
authorize services for CCS eligible
conditions.
Monitor treatment plan and patient Identify clients with CCS eligible
compliance. condition and refer to CCS for case
management ofthe CCS eligible
Communicate with Plan provider to condition(s).
assure continuity of care.
Provide medical records to CCS
Referral to community resources as appropriate to document CCS eligible
needed. condition(s).
Share medical information with Plan. Communicate with CCS to provide
Ensure CCS panel provider sends continuity of care.
progress reports to plan provider.
Information and referral to
Reviewand monitorPlan's referral community resources.
practices as feasible.
ProviderNetwork Act as consultant to the Plan and Primary responsibility forPlan
providers regarding CCS guidelines. provider training regarding CCS
eligible condition(s).
Quality Assurance Participate in and monitor quality assur- Responsible for developing and imp-
ance efforts through the Quality Council. plementing QA activities related to
members with CCS eligible condition.
Participate on service team to identify
gaps in care and barriers to access. Participate on joint CCS/Plan service
team to identify gaps in care and
Establish and maintain conflict resolu- barriers to access for Plan members
tion procedure for Plan members with with CCS eligible condition(s).
CCS eligible condition(s).
21
i
Flow Chart
CCS MANAGED CARE PLAN
Open CCS Case
Treatment need or Treatment need or
new DX identified new DX identified
by CCS panel by Plan
specialist provider
CCS Plan
Condition? No responsibility
Yes
Request Auth
from CCS
CCS Panel
Provider Bills
CCS
r
Flow Chart
CCS MANAGED CARE PLAN
NEW CASE
Primary Care Am
Suspects Condition
Does Initial Workup
No PCP Suspects
Eligible Condition
CSIOP
Yes Refers to CCS
CCS Process oCCNotfes
&Open Case Proder,Plan
Yesj,
(If necessary) CCS pays for Diagnostic
Evaluation by Specialist to R/O CCS
Condition
CS condition No CCS condition
found
Move to treatment CCS closes case &
CCS notifies notifies provider/
provider/plan plan