{"id":1151,"date":"2023-11-22T11:38:58","date_gmt":"2023-11-22T19:38:58","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=1151"},"modified":"2024-07-30T12:26:13","modified_gmt":"2024-07-30T19:26:13","slug":"3-1-6-population-and-care-management-services","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-1-complete-care-model\/3-1-6-population-and-care-management-services\/","title":{"rendered":"3.1.6 Population and Care Management Services"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Complete Care Model recognizes that patients have varied health care needs, and the delivery system needs to be flexible enough to serve a wide range of patients \u2013 from young, healthy patients without any history of chronic disease, to patients with multiple serious mental health, dental, and medical co-morbidities who require intensive services coordinated across multiple providers.\u00a0 The delivery system shall also include a wide range of social supports to maintain health and functioning.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>California Correctional Health Care Services (CCHCS) shall provide systematic assessment, risk stratification, monitoring, and care management of identified groups of patients at the statewide, regional, institutional, panel, and individual levels to meet the needs of a diverse patient population.\u00a0 Population management includes the evaluation of resources, processes and outcomes and is an integral component of the Complete Care Model and the Primary Care Team (PCT) function.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs and other health care staff are expected to provide services to patients commensurate with each patient\u2019s risk level and complexity to protect patients at risk for poor outcomes and ensure the most cost-effective allocation of scarce health care resources.\u00a0 Patients at higher risk utilize the most resources and represent the smallest percentage of the total population.\u00a0 Patients with complex health care needs exposed to the highest risk of permanent disability or death utilize the highest concentration of care management services (refer to figure below).<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>                                        Risk Levels and Actual Adverse Outcomes\/Resource Use<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><img loading=\"lazy\" decoding=\"async\" width=\"573\" height=\"347\" class=\"wp-image-1152\" style=\"width: 750px\" src=\"https:\/\/www.cdcr.ca.gov\/hcdom\/wp-content\/uploads\/sites\/207\/2023\/11\/Picture1.jpg\" alt=\"Includes a triangle that reflects the Proportion of the Total Population Represented in Each risk level with High Risk Patients at the top 10%; Medium Risk Patients in the Middle 30%; and low risk patients at the bottom 60%. In addition, there is an upside down triangle that represents the proportion of actual adverse Outcomes\/Resources Consumed, which shows the High Risk patients at the top, medium risk patients in the middle, and low risk patients at the bottom. \" srcset=\"https:\/\/www.cdcr.ca.gov\/hcdom\/wp-content\/uploads\/sites\/207\/2023\/11\/Picture1.jpg 573w, https:\/\/www.cdcr.ca.gov\/hcdom\/wp-content\/uploads\/sites\/207\/2023\/11\/Picture1-300x182.jpg 300w\" sizes=\"auto, (max-width: 573px) 100vw, 573px\" \/><\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CCHCS provides PCTs with guidelines, tools, and reports to support the provision of evidence-based care at all risk levels.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>This procedure describes the organization\u2019s risk stratification system, specifies the services generally appropriate for patients at different risk levels, and outlines processes for monitoring and managing patient populations, individual patients, and the components of the population and care management services delivery system.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Responsibility<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Statewide<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>California Department of Corrections and Rehabilitation (CDCR) and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available so that Care Teams can successfully implement the Population and Care Management Services Procedure.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Regional<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Regional Health Care Executives are responsible for implementation of this procedure at the subset of institutions within an assigned region.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Institutional<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Chief Executive Officer (CEO) has overall responsibility for implementation and ongoing oversight of a system to provide population management which includes risk stratification and care management.\u00a0 The CEO delegates decision-making authority to designated Institutional Health Care Executives for daily operations of the population and care management services system and ensures adequate resources are deployed to support the system.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CEO and all members of the institution leadership team are responsible for ensuring all necessary resources are in place to support the successful implementation of this procedure at all levels including, but not limited to the following:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Institution level<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient panel level<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient level<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CEO and all members of the institution leadership team shall ensure access to and utilization of equipment, supplies, health information system, patient registries and summaries, and evidence-based guidelines.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CEO and all members of the institution leadership team shall ensure protected time at least twice monthly, where each PCT shall conduct a Population Management Working Session utilizing tools such as Dashboards, Master Registries, Patient Summaries to address concerns related to potential gaps in care in order to improve patient outcomes including, but not limited to (refer to the <a href=\"https:\/\/cdcr.sharepoint.com\/sites\/cchcs_qm_com\/CCM%20Collaborative%20Materials%202016\/Forms\/AllItems.aspx?id=%2Fsites%2Fcchcs%5Fqm%5Fcom%2FCCM%20Collaborative%20Materials%202016%2F02%20Population%20Health%20Management%2FPop%20Mgmt%20Working%20Session%20Facilitator%20Guide%2020180207%2Epdf&amp;parent=%2Fsites%2Fcchcs%5Fqm%5Fcom%2FCCM%20Collaborative%20Materials%202016%2F02%20Population%20Health%20Management\" data-type=\"link\" data-id=\"https:\/\/cdcr.sharepoint.com\/sites\/cchcs_qm_com\/CCM%20Collaborative%20Materials%202016\/Forms\/AllItems.aspx?id=%2Fsites%2Fcchcs%5Fqm%5Fcom%2FCCM%20Collaborative%20Materials%202016%2F02%20Population%20Health%20Management%2FPop%20Mgmt%20Working%20Session%20Facilitator%20Guide%2020180207%2Epdf&amp;parent=%2Fsites%2Fcchcs%5Fqm%5Fcom%2FCCM%20Collaborative%20Materials%202016%2F02%20Population%20Health%20Management\">Population Management Working Session Facilitator&#8217;s Guide<\/a>):<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Trends in access to and quality of care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient risk stratification.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>High risk\/complex patients.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient safety alerts.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Resource Management (e.g., contract, supplies, equipment, space, environment).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Scheduling Reports.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Surveillance of communicable diseases.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CEO and all members of the institution leadership team as part of the Quality Management process on an ongoing basis shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Review and compare institutions\u2019 PCTs performance, including the overall quality of services, health outcomes, assignment of consistent and adequate resources, utilization of Dashboards, Master Registries, Patient Summaries, and decision support tools and address issues as necessary.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Provide PCT members with adequate resources, including protected time, staffing, physical plant, information technology, and equipment\/supplies to accomplish daily tasks.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Work with custody staff to minimize unnecessary patient movement that results in changes to a patient\u2019s panel assignment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Chief Medical Executive (CME) is responsible for overall medical management of patients and ensures resources are available to meet the medical needs of the population.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Chief Nurse Executive (CNE) is responsible for the overall daily clinic operations and ensuring that the institution has designated supervisors to monitor clinic operations including, but not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Efficiency.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Coordination.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Supplies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Equipment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Physical plant issues.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Scheduling and access to care on a daily basis.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identifying and addressing or elevating concerns regarding barriers.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The designated Supervising Registered Nurse (SRN) and the CME, or designee, shall meet weekly to review the PCTs\u2019 performance, including, but not limited to, the overall quality and efficiency of services, health care outcomes, and level of care utilization.\u00a0 The review shall utilize tools such as Dashboards, Master Registries, Patient Summaries, and decision support tools to address or elevate issues as necessary.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Determining Patient Risk<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Automated Risk Classification System<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>CCHCS shall maintain an automated system that continuously updates a patient\u2019s risk status based on the most current clinical information, including demographic, diagnostic, medication, specialty services, and inpatient data.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Within two calendar days of arrival at a Reception Center, all incarcerated persons shall be placed into the appropriate risk categories and be made available on the Master Registry.\u00a0 The Master Registry risk information shall be updated daily and made available to PCTs and other health care staff with need-to-know information (refer to Appendix 1, Clinical Risk Stratification Criteria).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Risk Verification<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Each PCT shall be responsible for verifying that a patient has been placed at the appropriate risk level.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Any time a PCT member determines that a patient may have been placed in the wrong risk category, the team member shall elevate the issue using the established process. \u00a0Refer to the <a href=\"https:\/\/cdcr.sharepoint.com\/sites\/cchcs_lifeline_rmb\/HCDOMResources\/Forms\/AllItems.aspx?id=%2Fsites%2Fcchcs%5Flifeline%5Frmb%2FHCDOMResources%2FClinical%20Risk%20Verification%20Process%2Epdf&amp;parent=%2Fsites%2Fcchcs%5Flifeline%5Frmb%2FHCDOMResources\" data-type=\"link\" data-id=\"https:\/\/cdcr.sharepoint.com\/sites\/cchcs_lifeline_rmb\/HCDOMResources\/Forms\/AllItems.aspx?id=%2Fsites%2Fcchcs%5Flifeline%5Frmb%2FHCDOMResources%2FClinical%20Risk%20Verification%20Process%2Epdf&amp;parent=%2Fsites%2Fcchcs%5Flifeline%5Frmb%2FHCDOMResources\">Clinical Risk Verification Process<\/a> available on the Lifeline Health Care Department Operations Manual Resources tab, for more detail on the communication process used to elevate discrepancies in risk classification.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Population Management Services Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Service Types and General Eligibility: CCHCS offers four levels of population management services (refer to Appendix 2, Population Risk and Resource Stratification Matrix):<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Primary Prevention: Services to promote health, prevent onset of disease, and maintain current health status such as immunization and screening.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Secondary Prevention: Services to treat one or more well controlled diseases to avoid serious complications.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Tertiary Prevention:\u00a0 Services to treat the advanced stages of one or more diseases and minimize disability and includes complex care management services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Catastrophic\/Complex Care: Services may range from restoring health to only providing comfort care and includes complex care management services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Primary Prevention Services Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs are responsible for providing patients within the assigned patient panel services to promote, maintain and improve health, prevent disease, and identify and manage the early onset of disease.\u00a0 This level of services may be provided by Licensed Vocational Nurses, Psychiatric Technicians, and Registered Nurses (RNs) functioning within their respective scopes of practice, in collaboration with other members of the PCT.\u00a0 To fulfill this role, team members shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Remain current on preventive services guidelines, eligibility criteria, and the priority prevention areas listed in the State Health Care Services Performance Improvement Plan.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Use eligibility criteria, available registries and reports to identify and monitor subpopulations within the patient panel.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Directly provide preventive services including administering immunizations as well as screening and identifying and addressing risk factors by early interventions such as medications, lifestyle modifications, self-management tools, patient education, and other strategies to promote and maintain health.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Applicable Guidelines<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall provide Primary Prevention Services to the patient population based on age-gender recommendations from the United States Preventive Services Task Force Guide to Clinical Preventive Services and consistent with Care Guides.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall utilize approved Nursing Protocols, Order Sets, Standing Orders, Care Guides, and other decision support tools when providing services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Secondary Prevention Services Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs are responsible for identifying and managing patients within the assigned panel who have one or more stable chronic diseases by providing services to halt progression and prevent serious complications. This level of services may be provided by RNs functioning within their scope of practice, in collaboration with other members of the PCT.\u00a0 To fulfill this role, team members shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Remain current on Care Guides issued by the Clinical Guidelines Committee, Nursing Protocols, Standing Orders, and other applicable evidence-based standards of care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Be aware of identified priority chronic disease management areas listed in the Statewide Health Care Services Performance Improvement Plan.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Use available registries and reports to identify and monitor subpopulations within the patient panel eligible for disease management services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Directly provide disease management services, including but not limited to, self-management planning and tools, patient education, routine ongoing evaluation of patient\u2019s health status and progress toward self-management goals, and adjustment of treatment strategies and interventions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Applicable Guidelines<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall utilize approved Nursing Protocols, Order Sets, Standing Orders, Care Guides, and other decision support tools when providing services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall reference other evidence-based guidelines if a Care Guide is not available for a specific condition.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Tertiary Prevention Services Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs are responsible for identifying and managing patients within the assigned panel who are in advanced stages of one or more chronic diseases to stabilize current disease state, slow progression and to mitigate further complications as well as minimize disability and maximize functioning and independence.\u00a0 This level of services may be provided by RNs functioning within their scope of practice, in collaboration with other members of the PCT.\u00a0 To fulfill this role, team members shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Remain current on Care Guides issued by the Clinical Guidelines Committee, Nursing Protocols, Standing Orders, and other applicable evidence-based standards of care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Use available registries and reports to identify and monitor subpopulations within the patient panel eligible for tertiary prevention services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Directly provide tertiary prevention services, including but not limited to, routine ongoing evaluation of patient\u2019s health status, adjustment of treatment strategies and interventions, reinforcing self-management planning and tools, patient education, and progress toward mutually agreed upon treatment goals.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Applicable Guidelines<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall utilize approved Nursing Protocols, Order Sets, Standing Orders, Care Guides, and other decision support tools when providing services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall reference other evidence-based guidelines if a Care Guide is not available for a specific condition.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Catastrophic\/Complex Care Management Services for High Risk and Clinically Complex Patients Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>High risk and clinically complex patients are at an exponentially higher risk for adverse health outcomes than the average incarcerated person and require more intensive assessment, monitoring, and treatment planning services to mitigate risk.\u00a0 Providing intensive services to this population is also an important utilization management (UM) strategy.\u00a0 While these patients comprise a small proportion of the total patient population (roughly ten percent), they consume more than half of the available pharmaceutical, specialty, and inpatient services.\u00a0 Although all PCT members shall have a role in complex care management, the Primary Care RN shall be the primary coordinator for complex care management services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs are responsible for identifying and managing patients within the assigned panel who have a very severe illness or condition and potentially significant risk factors.\u00a0 Services provided for these patients may have high costs with limited or no opportunity for improvement, stabilization, or cost control (e.g., end of life care, premature labor pregnancy complications).\u00a0 To fulfill this role, team members shall:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Remain current on Care Guides issued by the Clinical Guidelines Committee, Nursing Protocols, Standing Orders, and other applicable evidence-based standards of care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Use available registries and reports to identify and monitor subpopulations within the patient panel eligible for catastrophic care services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Directly provide catastrophic care services including, but not limited to, high intensity, direct, total and\/or specialized care of complex, complicated, unstable or high risk patients.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Coordinate this level of services with the UM Nurse, CNE, CME, and Chief of Mental Health, or their respective designees, and ensure services are provided by a multi-disciplinary team of health care providers including specialists and specialized care settings.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Applicable Guidelines<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall utilize Care Guides and California Code of Regulations, Title 22, when providing services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs shall reference other evidence-based guidelines if a Care Guide is not available for a specific condition.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Eligibility for Services<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patients with the following risk designations shall be provided complex care management services:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>High Risk 1.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>High Risk 2.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Clinically Complex.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The PCT may elect to offer complex care management services to additional patients, including, but not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Medium risk patients with deteriorating health status.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patients unwilling or unable to accept\/participate in treatment.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patients submitting multiple health care services requests for the same or similar complaints.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Multi-Disciplinary Plan of Care<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>All patients receiving health care services shall have a multi-disciplinary Plan of Care.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Plan of Care shall be developed by the PCT; at a minimum, this includes the Primary Care RN and PCP.\u00a0 Other disciplines shall be included as indicated by the patient care needs.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Detailed discipline-specific plans shall be developed as indicated by patient needs and integrated with the overarching Plan of Care (e.g., Wound Care Plan, Pain Management, and Mental Health Treatment Plan).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The Plan of Care shall be documented and maintained in the health record.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Population Management Working Sessions<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCTs are responsible for providing the bulk of population management services for patients within their assigned panel.<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CME or Chief Physician and Surgeon and the CNE or SRN III, and others as appropriate to the institution\u2019s mission and particular performance issues, shall hold working sessions conjointly with each institution Care Team at least twice monthly to ensure that teams have protected time to identify patient subpopulations and take action to address patient needs.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>At a minimum, core PCT members shall attend the Population Management Working Session.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>These working sessions offer a forum to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Update PCTs regarding new clinical guidelines and organizational changes relevant to primary care delivery.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identify barriers to care and resource needs.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Provide PCTs regular feedback about their performance in managing clinic work, coordinating patient services, and evaluating Care Team performance.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Assist Care Teams in managing subpopulations within the patient panel and improving patient outcomes.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Topics shall include, but are not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Patient registry flags and alerts indicating abnormal clinical findings and\/or missing documentation (e.g., CDCR 1845, Disability Placement Program Verification, CDCR 7410, Comprehensive Accommodation Chrono, Medical Classification Chrono, Medical Hold).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Trends in the PCT\u2019s performance on key Health Care Services Dashboard metrics as compared to statewide performance objectives, the statewide average, and the performances of other Care Teams at the institution.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Utilization of resources including, but not limited to, supplies, equipment needs, and contracts.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Access to care data and statistics.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Scheduling Reports (e.g., Aging Report, To Be Scheduled Report).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Potentially avoidable hospitalizations for any patients within the panel.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>New patients and patients leaving the panel in the context of their impact on the overall risk stratification of the patient panel (workload management and resource demand).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Mission changes that impact the patient panel (e.g., yard conversions, constructions, new programs).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Sustainability of Population Management Services<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Key Roles in Population Management and Patient Panel Allocation<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Institution leadership shall periodically review the roles and responsibilities of staff providing oversight or delivering population management services including, but not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>PCT members.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Clinic operations supervisor.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Public Health Nurses.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>UM Nurses.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Unit supervisors.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Penal Code 2602 coordinators.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Enhanced Outpatient Program coordinators.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Institution leadership shall ensure procedures, templates, and roles and responsibilities are updated as new tools and technology become available.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Institution leadership shall periodically review the composition of patient panels, particularly relative to the number and proportion of patients that fall into each risk category, to ensure available staff resources are distributed in order to provide the required population management services.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Training and Decision Support<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The CEO and institution leadership team shall establish an orientation and training program to ensure all staff serving as members of a PCT or supporting Care Team functions fully understand their roles and responsibilities prior to assuming their duties including, but not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Review of the expectations in this procedure.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Changes to local population management processes.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>National health care industry advances pertinent to the Patient-Centered Health Home.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>New information systems or technology that may increase the efficiency or effectiveness of Care Team processes or forums.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Updates in clinical practice, including new CCHCS clinical guidelines, standing orders, nursing protocols, industry best practices, and findings in clinical literature.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>During twice-monthly Population Management Working Sessions and in other forums, institutions shall provide staff involved in population management with training and information to support staff in providing high quality care, including, but not limited to:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>New guidelines and procedures.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Use of new technology and tools.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Effective processes and strategies in preventive care, disease management, and complex care management.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Best practices in the health care industry relative to population management, especially in the area of handoffs\/communication across different health care settings.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Common system lapses in the area of population management and ways to prevent these lapses from occurring.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Group review of specific patient cases for problem-solving and education.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Institutions shall assess the competence of staff performing population management work at least annually.\u00a0 Results shall be documented in the employee file and staff development training file.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Performance Evaluation and Improvement<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Designated Standing Improvement Committee<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Institution leadership shall designate an existing interdisciplinary standing committee reporting to the local Quality Management Committee (QMC) for oversight of the population management system monitoring activities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Evaluation<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The committee shall review population management performance trends and take action to improve care at least monthly.\u00a0 At a minimum, the committee shall review Health Care Services Dashboard information but may also consider monitoring reports, internal audits and surveys, and reviews by stakeholders such as court experts, the Prison Law Office, and the Office of the Inspector General.\u00a0 Beyond trends in performance metrics, the committee shall also consider the quality and effectiveness of program infrastructure, including, but not limited to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Culture of excellence and teamwork.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Communication between PCT members, PCTs, health care staff and custody, and with providers in other health care settings.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Health information flow, including registry and Patient Summary usage.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Resource allocation in accordance with panel composition.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>The extent to which daily huddle, Population Management Working Sessions, and Care Plan Conferences satisfy the purpose and requirements outlined in this procedure.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Competency of staff in key population management roles.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Decision support.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>System for orienting and developing staff.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Program monitoring and staff competency testing.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Committee Actions<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The committee may take a number of actions to improve program performance, including, but not limited to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identifying and prioritizing areas for improvement in population management.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Setting performance objectives.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Establishing improvement teams and\/or directly managing improvement initiatives.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Applying nationally-recognized improvement techniques to analyze quality problems and develop and test solutions.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Monitoring the progress of improvement initiatives at least monthly and intervening as necessary when initiatives stall or show a decline in performance.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identifying best practices and disseminating them across the institution.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Documenting improvement activity and results.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Regularly reporting performance trends and improvement activities to the QMC.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Ensuring that staff working in population management has the knowledge and skills necessary to contribute to improvement activities.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendices<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 1, Clinical Risk Stratification Criteria<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Appendix 2, Population Risk And Resource Stratification Matrix<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>References<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Code of Regulations, Title 22, Division 5, Chapter 12, Correctional Treatment Centers<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>California Penal Code, Part 3, Title 1, Chapter 3, Article 1, Section 2602<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>United States Preventive Services Task Force Guide to Clinical Preventive Services<br><a href=\"http:\/\/www.ahrq.gov\/professionals\/clinicians-providers\/guidelines-recommendations\/guide\/index.html\">http:\/\/www.ahrq.gov\/professionals\/clinicians-providers\/guidelines-recommendations\/guide\/index.html<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Agency for Healthcare Research and Quality \u2013 Patient Centered Medical Home Resource Center, <a href=\"https:\/\/www.act-center.org\/our-work\/primary-care-transformation\/patient-centered-medical-home\" target=\"_blank\" rel=\"noreferrer noopener\">Patient-Centered Medical Home | ACT Center (act-center.org)<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>The Joint Commission Primary Care Medical Home Certification, <a href=\"http:\/\/www.jointcommission.org\/accreditation\/pchi.aspx\">http:\/\/www.jointcommission.org\/accreditation\/pchi.aspx<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>National Committee for Quality Assurance \u2013 Patient-Centered Medical Home Recognition, <a href=\"http:\/\/www.ncqa.org\/Programs\/Recognition\/Practices\/PatientCenteredMedicalHomePCMH.aspx\">http:\/\/www.ncqa.org\/Programs\/Recognition\/Practices\/PatientCenteredMedicalHomePCMH.aspx<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Commonwealth Fund \u2013 Safety Net Medical Home Initiative, <a href=\"http:\/\/www.commonwealthfund.org\/interactives-and-data\/multimedia\/videos\/2011\/safety-net-medical-home-initiative\">http:\/\/www.commonwealthfund.org\/interactives-and-data\/multimedia\/videos\/2011\/safety-net-medical-home-initiative<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Robert Wood Johnson Foundation &amp; John Hopkins Bloomberg School of Public Health\/Chronic Care: Making the Case for Ongoing Care: <a href=\"https:\/\/publichealth.jhu.edu\/sites\/default\/files\/2023-04\/jhdaai-chartbook-2010.pdf\">Chronic Care: Making the Case for Ongoing Care (jhu.edu)<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Accelerating Care Transformation (ACT) Center, Kaiser Permanente Washington Health Research Institute: Reducing Care Fragmentation: A Toolkit for Coordinating Care: <a href=\"https:\/\/www.act-center.org\/application\/files\/7016\/3112\/2157\/Toolkit_Reducing_Care_Fragmentation.pdf\">https:\/\/www.act-center.org\/application\/files\/7016\/3112\/2157\/Toolkit_Reducing_Care_Fragmentation.pdf<\/a><\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 06\/2016<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 1:  Clinical Risk Stratification Criteria<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>Risk Category<\/strong><\/td><td><strong>Definition<\/strong><\/td><td><strong>Complex Care<\/strong><\/td><\/tr><tr><td><strong>High Risk 1<\/strong><\/td><td>Patients who trigger at least 2 of the following high risk selection criteria:<br>    \u2219 High Risk Diagnosis\/Condition: associated with current or future risk for adverse health event<br>    \u2219 Multiple Higher Level of Care Events:<br>         &#8211; Medical \u2013 2 or more community hospital admissions in the past 12 months<br>         &#8211; MH \u2013 3 or more MH higher level of care admissions in the past 12 months<br>   \u2219 Prolonged Medical Bed Stay: patients in CRC, OHU or a SNF\u226550% of the past 90 days<br>   \u2219 Polypharmacy: patients on 10 or more medications<br>   \u2219 High risk specialty consultations (e.g., oncologist, vascular surgeon)- 2 or more in past 6 months<br>   \u2219 65 years of age or older<br>   \u2219 Co-Morbid Medium Risk Diagnoses\/Conditions: a combination of \u201cmedium risk\u201d conditions which can be additive to increase the risk for future adverse health care events. (e.g., CKD with DM)<\/td><td>Patients who meet one or more of the following criteria:<br>  \u2219 Any mental health level of care higher than CCCMS<br>  \u2219 Risk level of High Risk 1 or 2<br>  \u2219 2 or more admissions to a mental health higher level of care in the past 6 months<br>  \u2219 Polypharmacy (taking 10 or more medications)<br>  \u2219 Any hospitalizations in the past 3 months<br>  \u2219 On medical hold<br>  \u2219 Special Outpatient Program status<\/td><\/tr><tr><td><strong>High Risk 2<\/strong><\/td><td>Patients who trigger at least one of the high risk selection criteria listed under \u201cHigh Risk 1\u201d above.<\/td><td><\/td><\/tr><tr><td><strong>Medium Risk<\/strong><\/td><td>Patients with at least 1 chronic condition who do not meet the selection criteria for high risk; includes patients enrolled in the Mental Health Services Delivery System and patients with permanent disabilities (under ADA) affecting placement.<\/td><td><\/td><\/tr><tr><td><strong>Low Risk<\/strong><\/td><td>Healthy patients who do not meet any of the selection criteria for medium or high risk; includes a subset of patients with well-managed\/stable chronic illness.<\/td><td><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Appendix 2:  Population Risk and Resource Stratification Matrix<\/strong><\/p>\n\t\t\t\t\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td><strong>Category<\/strong><\/td><td><strong>LEVEL 1:<\/strong><br><strong>Primary Prevention<\/strong><br><em>(Low Resource Use)<\/em><\/td><td><strong>LEVEL 2:<\/strong><br><strong>Secondary Prevention<\/strong><br><em>(Moderate Resource Use)<\/em><\/td><td><strong>LEVEL 3:<\/strong><br><strong>Tertiary<\/strong><br><em>(High Resource Use)<\/em><\/td><td><strong>LEVEL 4: Catastrophic\/Complex<\/strong><br><em>(Very High Resource Use)<\/em><\/td><\/tr><tr><td>Clinical Risk<\/td><td>Low Risk<\/td><td>Medium Risk<\/td><td>High Risk 2<\/td><td>High Risk 1<\/td><\/tr><tr><td>Goal<\/td><td>To prevent onset of disease and maintain current health status.<\/td><td>To treat a disease and avoid serious complications.<\/td><td>To treat the late or final stages of a disease and minimize disability.<\/td><td>May range from restoring health to only providing comfort care.<\/td><\/tr><tr><td><\/td><td>Healthy patients with no known diagnosis or complex treatments; however, may demonstrate warning signs or potentially significant risk factors.<br><br>Example:<br>\u2219 Healthy<br>\u2219 Blood glucose and lipids rising, but still within desired parameters.<br>\u2219 BMI elevated<br>\u2219 Smoker<br><br>Includes some patients with medical or mental health conditions considered to be well controlled or at low risk for adverse health event.<br><br>Example:<br>Otherwise healthy patients, including:<br>\u2219 Those who use \u2264 2 SABA dispenses in 12 months <strong><em>and<\/em><\/strong> not on an ICS<br>\u2219 Those with all HgA1C &lt; 7.7 in 12 months <strong><em>and<\/em><\/strong> not on insulin<br>\u2219 Those who only receive monotherapy for blood pressure management<br>\u2219 Those who are receiving treatment for LTBI <strong><em>and<\/em><\/strong> have AST &lt; 2Xs normal elevation<br>\u2219 CCCMS without medications or on a KOP SSRI only<br><br>Basic, uncomplicated\u00a0 nursing care of largely well population; prevention and wellness; stable, uncomplicated chronic disease; episodic care of acute injury or illness; routine care in primary care clinic; annual or semi-annual patient service plans (PSP).<br><br>Example:<br>\u2219 Independent ADLs<br>\u2219 Short term (no more than 4 weeks duration) conditions<br>\u2219 KOP medications or medication line no more frequent than BID<br>\u2219 Vital signs monthly, vital signs weekly for short period of time (no more than 4 weeks duration)<br>\u2219 Labs\/procedures\/treatments performed no greater than monthly except for situations as specified for short-term (no more than 4 weeks duration) medical conditions<br>\u2219 Independent wheelchair user and engaged in self management without complications.<br>Note: incarcerated person should be in an ADA designated facility.<br>\u2219 Independent prosthetic devices and engaged in self management without complications.<br>Note: incarcerated person should be in an ADA designated facility.<br>\u2219 Attend activities independently and willingly<br>\u2219 No thought disorder; no withdrawn or intrusive behavior<br>\u2219 Oriented, interacts appropriately<br>\u2219 Manages incontinence including indwelling catheters<br><em>[Most low risk patients will fall into this level\/category.]<\/em><\/td><td>Have diagnosis and\/or complex treatment; at higher risk for complications or potentially significant risk factors.<br><br>Example:<br>\u2219 Blood sugar and lipids not within desired parameters<br>\u2219 No support system<br>Includes patients with at least one chronic condition or mental health condition at higher risk for adverse health event.<br><br>Example:<br>\u2219 One or more chronic illness, based upon prescribed medications and\/or laboratory tests.<br>\u2219 CPAP with oxygen at night only<br>\u2219 Episodic oxygen therapy for acute asthma or respiratory condition no greater than twice a month<br>\u2219 CCCMS on NA\/DOT medications<br>\u2219 MH High Utilization<br>\u2219 Permanent ADA with history of\/or current complications<br>\u2219 Pregnancy<br><br>Low intensity nursing care of stable, chronic disease; functional limitations compensated by adaptive equipment; maintenance of status; prevention of exacerbation; symptom control and pain management; uncomplicated wound care (time-limited); uncomplicated chemo\/radiation therapy; Quarterly patient service plans (PSP).<br><br>Example:<br>\u2219 Independent in ADLs<br>\u2219 Stable, chronic disease<br>\u2219 Routine Medication Line: NA\/DOT, injectable and or transdermal medications.\u00a0 May also have KOP medications.<br>\u2219 PRN Medications: requires oral PRN medications including narcotics for significant physical symptoms.<br>\u2219 Vital signs daily for short period of time (not to exceed 2 weeks) to ascertain stability excluding vital signs required for certain medication such as pulse before administering Digoxin.<br>\u2219 Vital signs no greater than weekly excluding vital signs taken as required for certain medication such as pulse before administering Digoxin.<br>\u2219 Labs\/procedures\/treatments performed no greater than weekly for stable chronic disease excluding diabetic checks.<br>\u2219 Prosthetic devices with minimal assistance.<br>\u2219 Thought disturbance, effectual disturbance, withdrawn or intrusive behaviors requiring only redirection.<br>\u2219 Independent management of colostomies, incontinence including catheterization, and tracheotomies<br>\u2219 Wound care: uncomplicated, time-limited wound care or chronic stasis ulcers with independent dressing changes.<br><em>[Most medium risk patients will fall into this level\/category.]<\/em><\/td><td>Has diagnosis, complex treatment, and complications or potentially significant risk factors-goal is to prevent further complications.<br><br>Example:<br>\u2219 Has diabetes with early renal disease, coronary artery disease, failing eyesight and no support system.<br>\u2219 Three ER visits and two hospitalizations in past year<br>\u2219 Needs assistance with ADLs<br><br>Includes patients who are high risk priority 2 and trigger only <strong><em>1 flag<\/em><\/strong> from the selection criteria below:<br><br>Example:<br>\u2219 Medications associated with important diagnoses which, if not taken, may lead to a serious adverse event (e.g., immunosuppressant, chemotherapy)<br>\u2219 2 or more inpatient admissions in a 12 month period<br>\u2219 2 or more appointments to \u201chigh risk\u201d specialist(s) (e.g., oncologist, vascular surgeon) in a 6 month period<br>\u2219 65 years of age or older<br>\u2219 3 or more Mental Health Higher Level of Care admissions in the last 12 months<br>\u2219 In the CTC, OHU or SNF for 50% or more of the last 90 days<br>\u2219 Prescribed 10 or more medications<br>\u00a0<br>Medium intensity nursing care of complex, stable or at risk patients; uncomplicated post-surgical care; dementia, paraplegia, or hemiplegia able to participate in self-care; uncomplicated wound care (high risk for skin breakdown); Outpatient Housing Unit (OHU) placement; Monthly or every 2 month patient service plans (PSP).<br><br>Example:<br>\u2219 Requires some assistance with ADLs (bathing, feeding, dressing, toileting, etc.)<br>\u2219 Unstable, chronic disease, may require OHU placement<br>\u2219 Routine Medication Line: 3 or more NA\/DOT, injectable and or transdermal medications.\u00a0 May also have KOP medications.<br>\u2219 PRN Medications: requires oral PRN medications including narcotics for significant physical symptoms.<br>\u2219 Colostomy and\/or Foley catheter care requiring nurse intervention.\u00a0 If patient is stable and treatment is ongoing consider for placement in LTC facility.<br>\u2219 Frequent incontinency requiring nursing intervention \u2013 criteria for LTC<br>\u2219 Episodic incontinence including colostomies and indwelling catheters requiring nursing intervention \u2013 criteria for unstable chronic disease.<br>\u2219 Initiation of involuntary medications<br><em>[Most high risk priority 2 patients will fall into this level\/category.]<\/em><\/td><td>Have very severe illness or condition and potentially significant risk factors.&nbsp; May have high costs with limited or no opportunity for improvement, stabilization, or cost control (i.e., end of life care, premature labor pregnancy complications).<br>Example:<br>\u2219 Diagnosed with lung cancer<br>\u2219 Recent myocardial infarction<br>\u2219 Progression to ESRD with renal dialysis<br>\u2219 Amputation of one leg<br>\u2219 Blind<br>Includes patients who are high risk priority 1 and trigger at least 2<strong><em> flags<\/em><\/strong> from the selection criteria below:<br>Example:<br>\u2219 Medications associated with important diagnoses which, if not taken, may lead to a serious adverse event (e.g., immunosuppressant, chemotherapy)<br>\u2219 2 or more inpatient admissions in a 12 month period<br>\u2219 2 or more appointments to \u201chigh risk\u201d specialist(s) (e.g., oncologist, vascular surgeon) in a 6 month period<br>\u2219 65 years of age or older<br>\u2219 3 or more Mental Health Higher Level of Care admissions in the last 12 months<br>\u2219 In the CTC, OHU or SNF for 50% or more of the last 90 days<br>\u2219 Prescribed 10 or more medications<br>&nbsp;<br>High intensity, direct, total and\/or specialized nursing care of complex, complicated, unstable or high risk patients;&nbsp; daily care plan updates; significant dementia, paraplegia, hemiplegia, or quadriplegia unable to participate in self-care; Care management required; Inpatient level of care.<br>Example:<br>\u2219 Requires significant assistance or total care with ADLs (bathing, dressing, feeding, toileting, turning and positioning, ambulation and range of motion)<br>&nbsp;<br>\u2219 Level of Care: Acute medical or mental health inpatient, skilled nursing facility, LTC facility, Hospice or end of life care.<br>\u2219 NA\/DOT medications only<br>\u2219 IV therapy, blood and blood product transfusion, IV meds<br>\u2219 Daily vital signs, procedures or treatments for acute and unstable chronic disease excluding diabetic checks.<br>\u2219 Severe ill effects from chemotherapy and\/or radiation therapy<br>\u2219 Complicated wound care to include use of wound vac.<br>\u2219 Frequent suctioning<br>\u2219 Tracheostomy with extensive nursing intervention<br>\u2219 NG tube or G-tube feedings requiring total nursing intervention<br>\u2219 Routine incontinence requiring total nursing intervention.<br>\u2219 Colostomy and\/or Foley care that must be done by nurse<br>\u2219 Medical restraint (posey, soft wrist restraints, etc.) required for protection of self or to stabilize medical devices\/dressings\/tubes<br>\u2219 Confusion and disorientation secondary to dementia<br>\u2219 Thought disturbance, effectual disturbance, withdrawn or intrusive behavior that requires seclusion or restraint for protection of self and others<br>\u2219 Self-injurious behavior, 1:1 observation (acute mental health only)<br>\u2219 High Risk Pregnancy<br><em>[Most high risk priority 1 patients will fall into this level\/category.]<\/em><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":179,"template":"","class_list":["post-1151","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>3.1.6 Population and Care Management Services - Health Care Department Operations Manual (HCDOM)<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"3.1.6 Population and Care Management Services - Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-3-health-care-operations\/article-1-complete-care-model\/3-1-6-population-and-care-management-services\/\" \/>\n<meta property=\"og:site_name\" content=\"Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"article:modified_time\" content=\"2024-07-30T19:26:13+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"8 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-1-complete-care-model\\\/3-1-6-population-and-care-management-services\\\/\",\"url\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-1-complete-care-model\\\/3-1-6-population-and-care-management-services\\\/\",\"name\":\"3.1.6 Population and Care Management Services - Health Care Department Operations Manual (HCDOM)\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/#website\"},\"datePublished\":\"2023-11-22T19:38:58+00:00\",\"dateModified\":\"2024-07-30T19:26:13+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-1-complete-care-model\\\/3-1-6-population-and-care-management-services\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-1-complete-care-model\\\/3-1-6-population-and-care-management-services\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-3-health-care-operations\\\/article-1-complete-care-model\\\/3-1-6-population-and-care-management-services\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"HCDOM\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Chapter 3 &#8211; 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