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<br /> <br /> Page 34 of 48 <br /> <br />ii) Other state or local services currently used; <br /> <br />iii) Physical health conditions, including dental; <br /> <br />iv) Current and past behavioral and mental health and substance use status and/or <br />disorders; <br /> <br />v) Physical, intellectual developmental disabilities; <br /> <br />vi) Medications — prescribed and taken; <br /> <br />vii) Priority domains of social determinants of health (housing, food, transportation; and <br />interpersonal safety); <br /> <br />viii) Available informal, caregiver, or social supports, including peer supports. <br /> <br />(c) The Tier 3 AMH practice must have North Carolina licensed, trained staff organized at the <br />practice level (or at the CIN level but assigned to specific practices) whose job responsibilities encompass care <br />management and who work closely with clinicians in a team-based approach to care for high-need patients. <br /> <br />(d) For each high-need patient, the Tier 3 AMH practice must assign a care manager who is <br />accountable for active, ongoing care management that goes beyond office-based clinical diagnosis and treatment and <br />who has the minimum credentials of RN or LCSW. <br /> <br />15.13.3. Tier 3 AMH practices must use a documented Care Plan for each high-need patient receiving care <br />management. <br /> <br />(a) The Tier 3 AMH practice must develop the Care Plan within thirty (30) days of <br />Comprehensive Assessment, or sooner if feasible, while ensuring that needed treatment is not delayed by the <br />development of the Care Plan. <br /> <br />(b) The Tier 3 AMH practice must develop the Care Plan so that it is individualized and person- <br />centered, using a collaborative approach including patient and family participation where possible. <br /> <br />(c) The Tier 3 AMH practice must incorporate findings from the WellCare Care Needs <br />Screening/risk scoring, practice-based risk stratification and Comprehensive Assessment with clinical knowledge of <br />the patient into the Care Plan. <br /> <br />(d) The Tier 3 AMH practice must include, at a minimum, the following elements in the Care <br />Plan: <br /> <br />i) Measurable patient (or patient and caregiver) goals; <br /> <br />ii) Medical needs including any behavioral health and dental needs; <br /> <br />iii) Interventions, including medication management and adherence; <br /> <br />iv) Intended outcomes; and <br /> <br />v) Social, educational, and other services needed by the patient. <br /> <br />DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210