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provider contracts must be sent to the CCNC Program Ot~ice to enroll the provider in the Network and <br />qualify for monthly enhanced case management fees. <br />4.7 Maintain a network of health service providers to meet the medical needs of the Target Population. <br />4.8 Notify the CCNC Program Oftice with fifteen (1 S) days of any change within the Network organizational <br />structure. <br />4.9 Develop a policy and maintain a process to document and address complaints forwarded from the <br />Division of Medical Assistance to the Network. <br />4.10 Create a Network infrastructure to manage and support the Target Populations by: <br />• Ensuring Network staff includes one or more: pharmacist(s), nurses. social workers. and yuality <br />improvement specialist(s). <br />• Establish and fill the role of the "Network Pharmacist" who acts as the lead phannacy projects <br />manager for the network working under the direction of the Network Director. <br />• Establish an ongoing process with community providers and agencies to coordinate the <br />planning and provision of care management and support services for the target population. <br />• Support mental health integration by managing individuals with co-morbidities that include <br />behavioral health conditions. <br />4. t I Establish Network processes to support the care management of those in the Target Population that are <br />at highest risk and cost, to include, but not be limited to the following: <br />• Create an interdisciplinary team to help manage and optimize patient care; <br />• Perform health assessments and screenings. as appropriate; <br />• Develop patient-centered care plans; <br />• Promote a process to develop the skills necessary for patient self=management of chronic <br />conditions: and <br />• Utilize data summazies and reports created by the CCNC or NCCCN Inc. to identify those <br />individuals at greatest risk. <br />4.12 Develop a Transitional Care Program to support enrollees in the Target Population when discharged <br />from the hospital to include, but not be limited to: <br />• Collaborating with hospital discharge planners: <br />• Ensuring appropriate home based support and services are available; <br />• Implementing medication reconciliation in concert with the PCP and network pharmacist to <br />assure continuation of needed therapy following hospital discharge; <br />• Developing a Care Plan when there is a need for complex or high intensity care management: <br />• Ensuring appropriate follow-up appointments are made with PCP and / or specialists: <br />• Promoting the ability and confidence in self management of chronic illnesses in the Target <br />Population; and <br />• Providing care management and coordination support until the recently discharged enrollee <br />achieves stability in their home and community. <br />12 <br />