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.