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South Country Health Alliance | Nursing Home: Interdisciplinary Care Team

Nursing Home: Interdisciplinary Care Team

Interdisciplinary Care Team

  • 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.
    • Copy of the ICT Communication Form can be placed into the member’s nursing home chart where the PCP would review it when visiting the member in the nursing home.