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South Country Health Alliance | Elderly Waiver: Interdisciplinary Care Team

Elderly Waiver: Interdisciplinary Care Team

Interdisciplinary Care Team

  • Facilitate and assist the member to establish a relationship with a Primary Care Physician (PCP) and/or clinic and assist the member to complete an annual physician visit for primary and preventive care. The initial visit should be scheduled in the first 30 days of enrollment.
  • Provide written communication of significant health events, name, and contact information of the member’s case manager/care coordinator, and information from the member’s service plan for the PCP at least annually and as needed for emergency department visits, care transitions, and other events or services.
  • Use the template document ICT Communications Form (doc) in CCM under “Document Templates.”

    • Document in contact notes when the ICT Communication form was sent to the member’s PCP.