Current through Register Vol. 51, No. 19, September 20, 2024
A. The
Department shall reimburse for the care coordination services in this
regulation when these services have been documented, pursuant to the
requirements of this chapter, as necessary.
B. Care coordination services shall be
coordinated with, and may not duplicate activities provided as part of,
institutional services and discharge planning activities.
C. Care coordination may include contacts
that are directly related to identifying the needs and supports for helping the
participant to access services.
D.
The CCO shall engage in participant advocacy, including:
(1) Empowering the participant and, if the
participant is a minor, the minor's parent or guardian to secure needed
services;
(2) Taking any necessary
actions to secure services on the participant's behalf; and
(3) Encouraging and facilitating the
participant's decision making and choices leading to accomplishment of the
participant's goals or, if the participant is a minor, encouraging the parent
or guardian to carry out these decisions.
E. Comprehensive Participant Assessment and
Periodic Participant Reassessment.
(1)
Providers shall use a child and youth assessment tool approved by the
Department to perform participant assessments and reassessments.
(2) Initial assessment or reassessment
involves the participant's stated needs and review of information concerning
the participant's mental health, social, familial, educational, cultural,
medical, developmental, legal, vocational, and economic status to assist in the
formulation of a POC.
(3)The
initial assessment or reassessment of the participant's needs and progress
shall be facilitated by the care coordinator and monitored by the CFT, which
includes the participant, family members, and friends of the participant, as
appropriate, or, if the participant is a minor, the minor's parent or guardian,
and community service providers, such as mental health providers, medical
providers, social workers, and educators, as appropriate.
(4) Coordination and Facilitation of the CFT.
The care coordinator shall:
(a) Identify a
location for the CFT meetings that is suitable to the participant's
needs;
(b) Convene the CFT at least
every 6 months, or more frequently, as clinically necessary; and
(c) For 1915(i) participants, convene as per
the timeline and functions pursuant to COMAR 10.09.89.
(5) After an initial assessment, each
participant shall be reassessed at a minimum of every 6 months.
F. Development and Periodic
Revision of the POC.
(1) After the initial
assessment is completed, a POC shall be developed based on the information
obtained through the comprehensive screening and assessment tools approved by
the Department.
(2) The CCO shall
finalize the POC within 30 calendar days of notification of enrollment and
submit it to the Department or its designee.
(3) Development of and updates to the POC
shall be youth- and family-directed and managed through CFT meetings.
(4) The POC shall meet the requirements of
Regulation .12 of this chapter.
(5)
The POC development process shall include:
(a) The CFT meeting, which includes the
participant, and if the participant is a minor, the minor's parent or guardian,
providers, family members, and other interested persons, as appropriate, for
the purpose of establishing, revising, and reviewing the POC;
(b) The development of the written,
individualized POC based on the participant's strengths, needs, and progress
toward outcome measures;
(c)
Transitional care planning that involves contact with the participant or, if
the participant is a minor, the minor's parent or guardian, or the staff of a
referring agency, or a service provider who is responsible to plan for
continuity of care from inpatient level of care or an out-of-home placement to
another type of community service; and
(d) Discharge planning from care
coordination, when appropriate and when the family is closer to its identified
vision, when family needs have been met, and when outcome measures for care
coordination have been achieved.
(6) After the POC is developed, the CCO shall
update the POC as often as clinically indicated based on the strengths and
needs of the participant but not less than:
(a) For Level I participants, every 6
months;
(b) For Level II
participants, every 3 months;
(c)
For Level III participants, every 45 calendar days; and
(d) For all participants, within 7 calendar
days following a crisis event.