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Early Intensive Development and Behavioral Intervention Manual

Early Intensive Development and Behavioral Intervention Manual

Coordinated care conference

Page posted: 6/15/15

Page reviewed: 8/6/24

Page updated: 8/6/24

Legal authority

CMS-approved state plan amendment – 2017 (PDF), CMS-approved state plan amendment – 2018 update (PDF), CMS-approved state plan amendment – 2019 update (PDF), CMS-approved state plan amendment – 2022 update (PDF), Minn. Stat. §256B.0949

Definition

Coordinated care conference: An EIDBI service that covers a voluntary meeting between the person who receives services, their family, EIDBI provider(s), other service professionals and/or other people 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 considers coordinated care conferences a best practice to make sure a person with complex health needs has access to and receives appropriate and necessary care, including medically necessary:

  • · Speech therapy.
  • · Occupational therapy.
  • · Mental health services.
  • · Human services.
  • · Special education.

    • An EIDBI provider may recommend a coordinated care conference. The person’s parent(s) or legal representative may request a coordinated care conference.

    Eligible providers

    The following Minnesota Health Care Programs (MHCP)-enrolled EIDBI providers may participate in and bill for the coordinated care conference:

  • · CMDE provider.
  • · QSP.
  • · Level I provider.
  • · Level II provider.

    • Participants

    The coordinated care conference must include the person’s caregiver/legal guardian and/or the person.

    In addition to the providers eligible to bill for this service, the coordinated care conference may include:

  • · Personal care assistance (PCA) or direct support workers.
  • · 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, speech therapist, occupational therapist).
  • · School personnel.
  • · Case managers or care coordinators.
  • · Other providers, advocates or people the family requests.

    • Process

    The provider(s) should summarize the coordinated care conference(s) in the person’s ITP and health service record. For more information, refer to EIDBI – How to complete ITP and Progress Monitoring, DHS-7109 and EIDBI – Health service records.

    Initial coordinated care conference

    The person’s initial coordinated care conference should occur:

  • · After the person’s initial CMDE is complete.
  • · In conjunction with the development of the person’s ITP.

    • During the initial coordinated care conference, the participants:

  • · Review the CMDE results, including treatment options, caregiver/legal guardian’s preferences and provider recommendations.
  • · Discuss the caregiver/legal guardian’s preferences for treatment modality, scope, intensity, frequency and duration.
  • · Develop and coordinate the implementation of the person’s ITP based on the caregiver/legal guardian’s preferences and the CMDE results.
  • · Identify the amount and type of caregiver/legal guardian 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 or as needed based on medical necessity.

    In subsequent coordinated care conferences, the participants:

  • · Review the person’s progress toward goals and objectives documented in their 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 and/or discharge planning.

    • Case notes

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

    Telehealth

    If medically appropriate to the condition and needs of the person and family, a provider may deliver a coordinated care conference via telehealth. For more information, refer to EIDBI – Telehealth services.

    Service authorization and billing

    Coordinated care conferences:

  • · May occur on the same day as other EIDBI services.
  • · Do not require authorization.
  • · Can be provided as medically necessary.

    • For more authorization and billing information, including provider and service limits, refer to:

  • · EIDBI billing grid (PDF).
  • · MHCP Provider Manual – EIDBI – billing.
  • · MHCP Provider Manual – EIDBI – service authorization.

    • Additional provider responsibilities

    The provider(s) are 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 – CMDE
    EIDBI – CMDE provider
    EIDBI – Health service records
    EIDBI – How to complete ITP and Progress Monitoring, DHS-7109
    EIDBI – ITP development and progress monitoring
    EIDBI – Level I provider
    EIDBI – Level II provider
    EIDBI – QSP
    EIDBI – Services
    EIDBI – Settings for EIDBI services
    EIDBI – Telehealth services
    EIDBI billing grid (PDF)
    MHCP Provider Manual – EIDBI – billing
    MHCP Provider Manual – EIDBI – service authorization

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