Health Risk Assessment
- Participating Physician Groups (PPG)
Health plans must complete a health risk assessment (HRA) for members within 45 or 90 calendar days of the member's effective date of enrollment, depending on the members risk level, and then on an annual basis.
HRA completion assists Health Net and participating physician groups (PPGs) with early and ongoing identification of member needs, enabling Health Net and PPG care management teams to develop more comprehensive member-centric care plans. HRAs also predict future consumption of medical care and are imperative to the success of the care management program for both PPGs and Health Net. The HRA template includes questions to measure functional health and well-being from the patient's point of view and addresses the following areas:
- Member demographics
- Health history and medical conditions
- Current health and well being
- Activities of daily living
- Lifestyle and health behaviors
- Preventive care
The criteria provided by the Department of Health Care Service's (DHCS) is utilized to establish an initial high or low risk level for members based on 12 months of historical data from the Centers for Medicare & Medicaid Services (CMS) and DHCS. The outreach guidelines from DHCS are followed to contact newly enrolled members by telephone or mail to complete the HRA assessment.
The HRA is completed with the member within 45 calendar days of enrollment for members identified as high-risk, within 90 days for low-risk members, and annually thereafter for both low- and high-risk members. High-risk for risk-assessment purposes means members who are at increased risk of having an adverse health outcome or worsening health and functional status if they do not receive their initial contact within 45 calendar days of enrollment. Case managers and the member's primary care physician (PCP) have the option to complete the HRA for a member through a web-based HRA tool if the member prefers.
For members in nursing facilities, HRA are completed face-to-face by a Health Net vendor, PPG care managers or the member's PCP within 90 calendar days of enrollment.
If a member cannot be reached after the required attempts to complete an HRA, Health Net will send a letter to the member’s assigned PCP advising that the HRA was not completed.
The HRA is accompanied by a state-mandated support service assessment.
Health Risk Assessment Question and Answer Reports
The HRA Q&A report reflects the member's response to each individual question on the HRA. Once the HRA has been completed, it is posted on the Health Net provider website.
HRAs must be completed annually, but if there is a change in the member's clinical status, a PCP or care manager can request or complete an updated HRA prior to the anniversary of the previous HRA.
Individual Care Plan
The HRA and other available information (pharmacy history, medical records, etc.) is used by the care manager to establish/update the plan of care in collaboration with the member. The individual care plan includes specific, measureable goals and the interventions/actions to be implemented to reach the goals. The goals are prioritized based on the member preferences and care needs.
Interdisciplinary Care Team
An interdisciplinary care team is available for each member. The team consists of the member and the care team responsible for implementing the individual care plan.
The interdisciplinary care team is responsible for effectively managing member transitions, such as discharge from hospital to home. The care manager completes outreach and actions necessary to assure the member's discharge plan is in place and followed post-discharge.