As many plans are preparing to write a new Model of Care (MOC) for a new service area, an expanded service area, or redlining or revising an existing document, many plans miss the opportunity of evaluating the readiness of their Care Management team for change. The critical part of this team? The leadership.

I would like to challenge you as a leader of a care team or a care team member to think about the following and investigate or discuss these topics within your own organization:

Team Overview and Participants: Do you have the right design, or is a new design in order? Does your team have the right leadership? If so, does the leadership challenge the care team design by:

• Ensuring all lines of communication are open? This requires reviewing not only the data flow internally but also by spending time with the actual care team process and observing each and every person who touches your members and how effectively they carry out their roles.
• Establishing the correct protocols for care plan interventions? Many Special Needs Plan mock and CMS audits identify issues where the care team does not effectively identify the right intervention for the right member need. This can include associating a correct measurable outcome to the intervention. Often, systems auto-populate suggested interventions or suggested outcomes, but what really needs to happen is frequent, detailed review of the care plan content and how the members of the care team are associating outcomes and their due dates. Are they realistic? Are the time frames too far away from the actual identification of the need for an intervention?
• Establishing effective use of information and data points? How do you as a care team leader ensure your care managers, social workers, and care navigators know how to use or interpret lab or pharmacy data, not to mention where to find the data? As a care team leader, be sure to review all data sources from an IT perspective, that the data feeds are timely, and that staff knows how to interpret and use what they have access to.
• Ensuring community resources are appropriately identified? Many care plans miss the simple and free connections to community-based resources. The typical meals or transportation are often covered, but what about the more difficult items such as the actual office location where the member can obtain rental income assistance OR where is the address in the care plan/care plan notes that identifies the community loan closet where the member can obtain a raised toilet seat as it may not be a covered benefit? As their leader, help your care teams learn by ensuring they have the most up-to-date access to what they need when it comes to using community resources as, sadly, these connections could make a difference in whether a member is able to stay home and keep his or her independence.

An excellent leader of a care team digs into the actual work the care team members are doing, reviews the output of the Health Risk Assessment, and how the care team members translate the findings into a real member care plan – not a system template or repeatable care plan.

Many of these items could be included in an overall MOC performance marker to ensure the care team is measured not only on how many members they care for, but the actual true content of their care plans and recognizing all the needs of the member – not just those that can be quickly pre-populated by a basic care plan or system.

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