Comprehensive Care Management: The initial and ongoing assessment and care management services aimed at the integration of physical, behavioral health, long-term services and supports, and community services, using a detailed person-centered Health Action Plan (HAP).
Examples of Comprehensive Care Management may include :
Conduct outreach and engagement activities
Develop the HAP setting client centered goals and action steps
Complete comprehensive needs assessment such as the Patient Activation Measure
(PAM) and other required assessments for the HAP
Identify possible gaps in services and secure needed supports