For the past 28 years, the National Committee for Quality Assurance (NCQA) has been the leader in healthcare evaluation for health plan accreditation. NCQA evaluates health plans through a review of an organization’s adherence to a set of nationally developed standards and comparison to evidence-based performance measures.

Beginning with the 2007 Standards and Guidelines for Managed Care Organizations, NCQA included standards for Complex Case Management. The intent of the standard is to ensure that organizations are coordinating services for members with complex conditions, and assist them with access to needed sources.

NCQA divides its standards into measurable “elements.”  The Complex Case Management standard includes the following 9 elements:

·    Identifying members for case management using the following sources:

o    Claim or encounter data

o    Hospital discharge data

o    Pharmacy data

o    UM data

·    Access to case management through referrals from the following avenues:

o    Health information line referral

o    DM program referral

o    Discharge planner referral

o    UM referral, if applicable

o    Member self-referral

o    Practitioner referral

·    Availability of effective case management systems:

o    Evidence-based clinical guidelines or algorithms to conduct assessment and management

o    Automatic documentation of the staff member’s ID, and date and time action on the case, or interaction with the member occurred

o    Automated prompts for follow-up, as required by the case management plan

·    A case management process that meets industry-wide standards:

o    Members' right to decline participation or disenroll from case management programs and services offered by the organization

o    Initial assessment of members' health status, including condition-specific issues

o    Documentation of clinical history, including medications

o    Initial assessment of the activities of daily living

o    Initial assessment of mental health status, including cognitive functions

o    Initial assessment of life-planning activities

o    Evaluation of cultural and linguistic needs, preferences or limitations

o    Evaluation of caregiver resources

o    Evaluation of available benefits

o    Development of a case management plan, including long-term and short-term goals

o    Identification of barriers to meeting goals or complying with the plan

o    Development of a schedule for follow-up and communication with members

o    Development and communication of member self-management plans

o    A process to assess progress against case management plans for members

·    Initial assessment of patients that meets the organization’s process

·    Ongoing management that meets the organization’s process

·    Evaluation of satisfaction with the case management program using member feedback and complaints