Integrate Community Resources Into NCQA Case Management

By Nancy Ross Bell, RN

Estimated time to read: 4 minutes

A crucial element of Population Health Management (PHM) is the evaluation and integration of community resources to support member care. By understanding the specific needs of members, organizations can more effectively connect individuals with appropriate activities and programs. This integration is especially important for members who qualify for complex case management (CCM).

Read here why community resources matter, how they are connected to the NCQA standards for CCM, and key points for CCM file reviews.

Note: Not all standards, elements, and factors are identified in this blog. Always refer to NCQA’s most current standards for all requirements.  CCM is found in HPA PHM 5 and MBHO QI 8.

Why Does This Matter?

While the types of community organizations vary, the integration of community resources into a member’s care plan is highly advantageous because it:

• supplements what health plans are contracted to do.
• connects the organization directly with the member.
• is often administered to underserved or vulnerable populations.
• is often served by individuals who have local ties to the population.
• helps bridge gaps in access to care and services.
• provides ongoing support for chronic condition management.
• helps lower costs for those who are housing or food insecure.
• can enhance the health of the population through preventative care services and education.

Community resources are integral to CCM programs within the context of PHM for NCQA Health Plan (HP) Accreditation, Case Management for NCQA Case Management (CM) Accreditation, and Quality Management & Improvement for NCQA Managed Behavioral Health Organization (MBHO) Accreditation. Organizations are called to intentionally integrate community resources to help make care more accessible and targeted to members’ needs.

What Does Intentionally Integrating Community Resources Look Like?

Here is an example of how one health plan successfully integrated community resources into its PHM program for CCM.

Starting with its Population Assessment, the health plan identified two subpopulations with significant needs.

• The Latino immigrant population needed community transportation and improved communications for limited English proficiency (LEP).
• Pregnant minority women were financially insecure.

Next, the health plan collaborated with multiple community partners and took seven impactful actions.

• Established wellness centers throughout their communities where high concentrations of Latino members reside.
• Provided multilingual interpreters where needed.
• Arranged offices for case managers, social workers, health coaches, and pharmacists for medication management and face-to-face assessments.
• Offered health education, diabetes screening events, and wellness activities for adults and kids.
• Held quarterly community baby showers and diaper days for pregnant moms in case management.
• Issued free bus passes to help members get to regular medical appointments.
• Linked members with local food resources and housing.

Case Managers, Social Workers, and Pharmacists documented their evaluations, interventions, and follow-ups in their Case Management System.

The Population Assessment Identifies Needs  

Using data collected from claims, encounters, lab, pharmacy, utilization management, socioeconomic data, and demographics, the organization annually identifies the needs of its population (PHM 2B Explanation).   

The needs of the population are collected on six specific factors (PHM 2B Factors 1-6):

• Population characteristics, including social determinants of health (SDOH)
• Children and adolescents
• Individuals with disabilities, serious mental illness, or serious emotional disturbances
• Members of racial or ethnic groups
• Members with limited English proficiency (LEP)

Using this information, the organization further assesses the characteristics and needs of at least two relevant subpopulations (PHM 2B Factor 7).

Activities & Resources Help Meet Member Needs

Programs and services initially identified in the organization’s PHM Strategy are subsequently reviewed and updated based on the needs identified in the organization’s annual Population Assessment (PHM 2C Factors 1 and 2).

Using the Assessment, healthcare disparities are identified among all members of racial or ethnic minority groups and members with LEP. Programs, services, activities, and resources are reviewed, with at least one updated to address the discovered disparity (PHM 2B Factor 3).

Based on the identified needs from the Population Assessment, the organization connects members to community resources or promotes community programs to its members (PHM 2B Factor 4).

To help with your documentation, MHR offers a suite of tools, templates, and guides to fulfill requirements for PHM standards. The PHM suite includes standards-specific PHM-Strategy Guide, Strategies Catalog Template, Strategy Template, Population Health Assessment Guide, Population Assessment Templates, Data Methodology and Collection Guides, Population Assessment Mind Map, and Strategy Effectiveness Analysis Template.

Community Resources That Must Be Included

Organizations must have Policies and Procedures to assess individual members’ eligibility for community resources that supplement those the organization has been contracted to provide (PHM 5C Factor 11).

Community resources can take on different views depending on the needs of its population. At a minimum, the organization must include the following resources:

• Community mental health
• Transportation
• Wellness organizations
• Palliative care programs
• Nutritional support

Complex Case Management & Community Resources

Following the organization’s procedure for segmenting or stratifying members, those eligible for complex case management are identified.

Once identified, an Initial Assessment is conducted by a Case Manager with evaluations of the person’s:

• Cultural and linguistic needs, preferences, or limitations
• Visual and hearing needs, preferences, or limitations
• Caregiver resources and involvement
• Available benefits
• Available community resources (PHM 5D Factors 6-10).

It is here where the case manager determines and documents the following:

• if current resources are sufficient to meet the member’s needs according to their CCM treatment plan
• if the member is eligible for the resources
• if the supplemental resources are available within the community

After intentionally integrating the resources through referrals and assistance to access, the effectiveness of the community resources is evaluated and documented in the Case Management System along with any updates to the plan in the Ongoing Assessment.

Remember the Conclusion!

In the Initial Assessment, community resources are incorporated in a written conclusion by the case manager. Conclusions are reviewed during the NCQA file audit.  Case management plans document member resource needs, facilitation of referrals and follow-up activities.

Key points to include in written conclusions and ongoing management documentation are:

• what was assessed
• member eligibility and availability of community resources
• specific community resources included in the treatment plan
• whether resources met the member’s needs 

Intentional Integration Means Action!

What Is not an intentional integration of community resources is simply posting programs on a health plan’s website.

What it is is documentation evident in case files that shows: 

• community resources correlate with the member’s documented needs
• members are connected with community resources by referral and assistance to access the services

PHM 5D and PHM 5E File Reviews and Audits

The health plan demonstrates that it follows its Case Management Policies and Procedures for the Initial Assessment & Ongoing Management of members in complex case management programs through file review.

Evaluation and integration of community resources is just one factor.

File reviews for PHM 5D and PHM 5E are complex due to their numerous factors. MHR offers file review prep guides and an audit tool to help you comply.

A File Review Guide explains each factor with tips from MHR Consultants on documentation.

A File Review PDF Instructions and Template explains setting up your files, bookmarking, annotating, and text boxes.

A File Audit Tool is an expanded Excel file for documenting NCQA audit findings of individual case management files. Each factor is listed in a row across with space to add individual file numbers. As the auditor scores the file, results are tabulated with a percentage of compliant/non-compliant.

Automatic Credit & MAC Survey

• Organizations may be eligible for automatic credit if delegating to an NCQA Prevalidated Health IT vendor for certain Elements.
• For organizations considering a Merger, Acquisition, or Consolidation, Complex Case Management is scored as part of a MAC Survey.

Refer to the appropriate Appendix in your Accreditation Standards.

Call to Action

MHR offers personalized attention and customized solutions for customers going through their first accreditation, renewal survey, or working to sustain their accreditation. With annual updates to NCQA standards, our expert consultants will guide you in taking action to meet requirements.

• If you are not an MHR client, schedule a Discovery Call to learn more about MHR’s NCQA Accreditation Consultation and our proprietary training, tools, and templates.
• Schedule MHR’s NCQA Training for HP, CM, and MBHO on the Products/Training page
• Review MHR’s tools & templates on the Products/Tools & Templates page

For more information, contact your MHR Consultant or email us at [email protected]

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MHR follows a quality review process for all blogs. This blog was written with insights from Dena Reeves, RN. Please read more about Dena and MHR’s other Independent Consultants at ManagedHealthcareResources.com/About Our Consultants.  

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