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Coordinated care conference (also known as a medical team conference)

Date posted: 6/15/15

Date reviewed: 2/21/17

Date updated: 1/2/19

Legal authority

CMS-approved state plan amendment (PDF), Minn. Stat. §256B.0949

Definition

Coordinated care conference (also known as a medical team conference): An EIDBI service that covers a voluntary, face-to-face meeting between the person, his/her family, EIDBI provider(s), other service professionals and/or other individuals the person/family requests to:

  • • Review the comprehensive multi-disciplinary evaluation (CMDE) or individualized treatment plan (ITP)
  • • Integrate and coordinate services across providers and service-delivery systems to develop the ITP.
  • Overview

    DHS views the coordinated care conference as best practice to ensure a person with complex health needs has access to and receives appropriate and necessary care, including medically necessary speech therapy, occupational therapy, mental health, human services and/or special education.

    Either a CMDE provider or qualified supervising professional (QSP) may suggest a coordinated care conference, but it is the person’s parent or legal representative’s decision to request the conference.

    Eligible providers

    The following MHCP-enrolled EIDBI providers may participate in and bill for the coordinated care conference:

    If the following providers are enrolled with MHCP, they also may participate in and bill for the coordinated care conference:

  • • Advanced practice registered nurse (APRN)
  • • Physician.
  • Participants

    The coordinated care conference must include:

  • • The person’s parent(s)/legal representative
  • • A qualified supervising professional (QSP)
  • • A minimum of three providers from different specialties or disciplines (each of whom must provide direct treatment to the person).
  • In addition to the providers eligible to bill for this service, the conference also may include:

  • • Personal care assistants (PCA)
  • • Family members or other primary caregivers
  • • Licensed professionals who work with the person or family or whose services may be needed (e.g., mental health)
  • • Rehabilitative services personnel
  • • School personnel
  • • Other providers or individuals the family requests.
  • Process

    The QSP should document each coordinated care conference in the Individual Treatment Plan (ITP) and Progress Monitoring, DHS-7109 (PDF). For more information, see EIDBI – How to complete ITP and Progress Monitoring, DHS-7109.

    Initial coordinated care conference

    The initial conference should occur:

  • • After the person’s initial CMDE is complete
  • • In conjunction with the development of his/her initial individual treatment plan (ITP).
  • During the initial coordinated care conference, the participants:

  • • Review the CMDE results, including treatment options, parent/legal representative preferences and provider recommendations
  • • Discuss the parent/legal representative’s preferences for treatment modality, scope, intensity, frequency and duration
  • • Develop and coordinate the implementation of the person’s individual treatment plan (ITP) based on the parent/legal representative’s preferences and the CMDE results
  • • Identify the amount and type of parent/legal representative involvement in the person’s treatment
  • • Coordinate EIDBI services with other services the person and family receives
  • • Refer the person or family for other services, if needed.
  • Subsequent coordinated care conferences

    Subsequent coordinated care conferences should occur in conjunction with ITP progress monitoring updates.

    In subsequent coordinated care conferences, the participants:

  • • Review the person’s progress toward goals and objectives documented in his/her ITP
  • • Document decisions or changes in the ITP
  • • Discuss other service updates, as applicable
  • • Continue to coordinate EIDBI services with other services the person and family receives
  • • Refer the person or family for other services, if needed
  • • Discuss transition planning.
  • Coordinated care conferences requested by parent/legal representative

    A coordinated care conference may occur when requested by the parent/legal representative. During these conferences, the participants:

  • • Review the person’s progress toward goals and objectives documented in his/her ITP
  • • Document decisions or changes in the ITP
  • • Discuss other services updates, as applicable
  • • Coordinate EIDBI services with other services the person and family receives
  • • Discuss transition planning.
  • Case notes

    The provider must document the coordinated care conference in the person’s case notes. For more information, see EIDBI – Health service records.

    Telemedicine

    If medically appropriate to the condition and needs of the person and family, family/caregiver training and counseling may be provided via two-way, interactive video. For more information, see EIDBI – Telemedicine services.

    Service authorization and billing

    Coordinated care conferences may occur on the same day as ITP. A coordinated care conference cannot be billed on the same day a person receives other EIDBI services.

    Do not bill this service if your participation in the coordinated care conference is part of a contractual obligation and covered by your facility or organization.

    For additional authorization and billing information, including provider and service limits, see:

    Additional provider responsibilities

    The QSP is responsible to:

  • • Arrange for an interpreter to attend the conference, if needed
  • • Coordinate and schedule the conference with the person and parent/legal representative
  • • Notify service professionals or other people who need to attend.
  • Additional resources

    EIDBI – Comprehensive multi-disciplinary evaluation (CMDE)
    EIDBI – EIDBI services

    EIDBI – Individual treatment plan (ITP) development and progress monitoring

    EIDBI – Settings for EIDBI services

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