The Model of Care’s Interdisciplinary Care Team
The Centers for Medicare & Medicaid Services (CMS) has outlined expectations for Model of Care (MOC) for Medicare managed care programs. One of the critical elements of the MOC is the Interdisciplinary Care Team (ICT). CMS has placed greater emphasis on outcomes measures and a well-designed ICT can be a success factor in improving the quality of care and service afforded to beneficiaries.
The health plan case manager after initial member assessment is responsible for developing goals / objectives and barriers to improving member health. The case manager is charged with identifying relevant personnel for the ICT that holds accountability for developing a comprehensive Individualized Care Plan (ICP) addressing the beneficiary’s particular needs.
The ICT’s duty is to review multiple sources of information: health risk assessments (HRA), medical and pharmacy claims, risk profiles, patient goals / objectives and barriers in order to create a robust ICP; in addition to managing the beneficiary’s clinical and psychosocial needs and working with the case manager to coordinate the delivery of required services and benefits.
Each ICT is required to update the ICP and define the appropriate frequency of ICP reviews and revisions. It is also responsible for notifying beneficiaries / designees, primary care providers, and relevant specialist(s) of meeting dates. Depending on case volume ICT meetings can vary from weekly, bi-weekly or monthly whichever is relevant to the identified goals and objectives. Each meeting should have a prepared agenda and case summary that’s shared with the beneficiary, providers and specialists in advance. Attempts to schedule meeting times that maximize beneficiary and provider participation are beneficial.
Numerous health plans struggle with the formation of an Interdisciplinary Care Team. If you are uncertain or concerned that your plan does not have a solid ICT process or design, GHG can assist you in evaluation and identification to adhere to best practices.
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