Health Home Application Provider Training

1. Health Home ApplicationProvider Training Ohio Department of Mental Health14 June 2013

2. Who Must Use This Application • Phase 1 providers that had not submitted an application to ODMH by June 4, 2013 • All Phase 2 providers • What this Training Will Cover • How to fill out & submit an application to provide health home service • What this Training Will NOT Cover • What is a Health Home • How to develop health home service for your agency • HOWEVER • The application was designed to guide an agency through the requirements to develop a health home service • Agency needs to individualize the sections to describe its own model for health home service

3. Proposed Revised Rule 5122-29-33 • Currently in Common Sense Initiative comment period • Application is based upon proposed rule • Comment until June 19, 2013 • http://mentalhealth.ohio.gov/what-we-do/protect-and-monitor/licensure-and-certification/rules/draft-rules.shtml

4. When is the Application Due? • The Office of Licensure and Certification will appreciate it if Phase 2 applications are submitted by August 1, 2013 • This is not a deadline, but will help the process d/t the anticipated large number of applications • However, L/C is committed to doing everything possible to ensure that all applications received are processed in a timely manner before October 1st • August 1st time frame should allow the Department enough time to review the application and gain additional information from the provider if there are missing elements from the application • ODMH cannot guarantee Certification will be granted by October 1, regardless of when an application is received – an incomplete (missing documents or information) or non-compliant (not in compliance with the rules) application can delay the effective date • Effective date of certification is date agency submits a complete and compliant application, and will be on or after October 1 (Phase 2) • Effective date for Medicaid billing may be later than date of certification

5. Why is the Application So Detailed? • Normal process to add non-deemed Medicaid billable service includes ODMH conducting an on-site survey AFTER provider has begun to provide services so that ODMH can review clinical records • This application allows ODMH to certify service without requiring provider to first provide health home service for a month or longer (without ability to bill), then have ODMH conduct an on-site survey • Under this scenario, if on-site resulted in Plan of Correction (POC), provider would not be eligible to bill Medicaid for services provided prior to on-site and date of approved POC

6. Throughout the application, providers will be asked to: • Provide data (name, addresses, etc.) • Answer checkbox questions • Describe or explain • Use Narrative • Attach • Include agency documentation, e.g. policies and procedures, with application • Please label all attachments submitted with this application with the appropriate application section title and number/letter

7. Provider Eligibility to Apply (D) ODMH certified for each of the following services: (1) Behavioral health counseling and therapy; (2) Mental health assessment; (3) Pharmacological management; and (4) Community psychiatric support treatment.

8. Suggested Steps to Design Health Home Service • Describe population to be served (target population) • Physical health needs/chronic medical conditions, behavioral health needs, utilization, age, etc. • Decide on integrated care model – how will primary care be delivered • If not using ownership/membership, enter into agreements • Determine capacity – how many persons meet your agency’s target population • Develop policies and procedures for health home service, including delivery of primary care • Should be based upon the target population needs, and not be generic or “cookie-cutter” • Develop form templates

9. Tasks to Design Health Home Service • Identify needed partners, i.e. providers/entities with whom the agency will develop working relationships • Based upon the needs of the target population • Define roles in coordinating and managing care • How will data be exchanged • On-going – update as needs of target population change • Develop job descriptions and identify staff who will fill each role on the health home team • Within the four positions, what competencies are needed to meet the target population needs

10. Tasks to Design Health Home Service Remember the 6 Components of Health Home Service. Include in development of health home program description & policies and procedures [See 5122-29-33 (C) for detailed information on activities]: • Comprehensive Care Management • Care Coordination • Health Promotion • Comprehensive Transitional Care and Follow-up • Individual & Family Supports • Includes expanded access • Referral to Community and Social Support Services

11. Tasks to Design Health Home Service • Develop tools/templates for health home service delivery • Comprehensive assessment • Comprehensive assessment update • Integrated care plan • Communication plan – routine exchange of information with consumer, family/significant others, health home team, primary care providers, specialist, partners, managed care plans • Crisis management and contingency plan • Clinical summary report • Develop procedures/protocols for information exchange & coordination of care with consumer, family/significant others • Develop policies, procedures, protocols on Comprehensive Care Management & Care coordination • Communication, exchange of data, assist consumer in accessing needed services, medication management including med reconciliation, track tests, make referrals and follow-up as necessary.

12. Tasks to Design Health Home Service • Health Promotion activities. Preventative and Disease Management. Two levels: • Individual specific, e.g. John needs to quit smoking • Different for each consumer • Target population, e.g. Offering smoking cessation classes • On-going. Will change over time as assessed needs change, e.g. initially may develop smoking cessation and exercise programs, & nutrition classes. In one year, number of individuals on health home with diabetes increases from 15% to 45%, so agency adds diabetes specific classes specific to managing chronic diabetes – teaching individuals to track blood pressure; check their feet for cuts, blisters, etc. and to notify health home team & primary care doctor of sores that do not go away, etc. • Use evidenced-based, informed, best, emerging and/or promising practices/ • Transitional care • Work with partners and others to prevent adverse outcomes • Having partnerships in place will • Post-discharge services & follow-up

13. Tasks to Design Health Home Service • Develop Outreach Plan • Data Sharing & Information Management • Develop capacity and strategies • Used to inform care management and care coordination • Electronic Health Record • Certified by national Coordinator for Health Information Technology • If agency does not have one, develop plan to acquire within 12 months of certification • Staff and financial resources needed • Health Information Exchange • If not participating, develop plan

14. Please Note • Task list is not exhaustive • Please consult rule 5122-29-33 and other training resources

15. Now the Application…

16. Agency Profile DataPage 1 • Remember to list all anticipated sites and the information for each • Health home sites must be certified by ODMH • Same requirement as for other certified services • Routine locations where providing the service • Do not need to certify primary care locations (unless co-located with agency) or community locations

17. Health Home Service PopulationPage 2 • Applicant must demonstrate an understanding of the eligible populations to be serves in the Health Home by addressing key characteristics, including: chronic medical conditions; SPMI/SMI/SED; utilization, rates; locations; age; and culture. • References data that will soon be available for applicants. • This data is not currently available, but will be shared in the near future. • Will be available on the web, by county and provider • Future webinars will be scheduled

18. Health Home Service Providers are required to: • Ensure capacity to serve all eligible consumers within the designated service area • Provide health home service to ONLY eligible consumers • Use the criteria for serious and persistent mental illness (SPMI), serious mental illness (SMI) and serious emotional disturbance (SED) as described in the rule when identifying eligible consumers • Determine the eligibility of consumers for the health home service Target PopulationHealth Home Service Requirements

19. ODMH does not prescribe a specific format or methodology • Health home providers are not required to show proof or documentation of the methodology used for determining consumer’s eligibility • Health Home providers may use a combination of approaches when identifying eligible consumers such as: • EHR based identification • Medical Record Review by Group or Individual Staff • Standardized Form Target PopulationMethodology for Identifying Eligible Consumers

20. Referral Sources for Health Home Service may include: • Hospital Emergency Departments (mandatory referral source) • Hospital Inpatient Psychiatric Units • Managed Care Plans • Mental health treatment providers • Specialty providers • County children services • Self-referrals • Other community providers • Health Home Provider should: • Inform potential referral sources about referral process and capacity • Train intake staff regarding health home service referrals • Respond and accept referrals in a timely manner • Track number and type of referrals, and wait time • Follow up with the referral sources on the outcome of the referrals and • Provide an explanation of the reasons for denial of the health home service as appropriate Target PopulationManaging Referrals to Health Home Service

21. Behavioral and Physical Health IntegrationPage 2 • List Integrated Care Accreditation or Certification • If agency does not currently have, list anticipated date by which you expect to obtain

22. 5122-29-33 (F) (F) A health home provider shall demonstrate integration of physical and behavioral health care by achieving one of the following: (1) Successful implementation of accrediting body integrated physical health/primary care standards during the next accreditation survey process following Ohio department of mental health certification as a health home provider in which the provider is eligible in accordance with its accrediting body policies and procedures to undergo a review of its integrated physical health/primary care services: (a) Integrated behavioral health/primary care or health home core program accreditation by the commission on accreditation of rehabilitative facilities; or (b) Primary physical health care standards by the joint commission behavioral health care accreditation program; or (c) Integrated behavioral health and primary care supplement standards by the council on accreditation; or (d) Equivalent accreditation or certification approved by the Ohio department of mental health; or (2) Within eighteen months: (a) Level one patient-centered medical home recognition by the national committee for quality assurance; or (b) Patient-centered specialty practice recognition by the national committee for quality assurance; or (b) (c) Equivalent accreditation, certification or recognition approved by the Ohio department of mental health.

23. Behavioral and Physical Health IntegrationPage 2 • Integrated Care Model, Health Home and Primary Care • Describe your behavioral health and primary care integration model and how your model addresses how, where, when and what primary care is provided, how the primary care and health home provider collaborate in areas such as referrals, communication, information sharing and medical record management, staffing arrangements and supervision, and financial arrangements. • How will your agency provide integrated care and incorporate the use of data in health home service in order to achieve positive consumer outcomes • Reference SAMHSA Six Levels of Collaboration • How does your model fit population and capacity needs

24. Behavioral and Physical Health IntegrationPage 2 • Attach a copy of your primary care service plan. • Oops, should say “Applicants with Ownership/ • Membership” in providing primary care (See bottom Page 3) • Applicants with health home coordinated and co-located care integration models • Attach a copy of your agreements with primary care providers. Agreements must include the following: educational materials/training that will engage providers; information that will be exchanged between the health home and provider; and role of providers in coordinating and managing care, including integrated care plan development and updates, team meetings and communication protocols.

26. Table APage 3 • Another “oops” in column (E) • Fill out if providing primary care via ownership/membership • Health Home Site(s), Integrated Care Model(s), Primary Care Capacity and Expanded Access • Checkboxes and simple descriptions • Allows for potential of different models of integration at different locations • Demonstrate expanded access (check all that apply) • Identify capacity • Location(s) of primary care provider(s) • Use as many copies as needed for site/model combinations

28. Primary Care Screening Assurance ChecklistPage 4 • Checkboxes for provider to attest to the ability to ensure primary care screening and treatment services • Utilized to monitor physical health status, monitor outcomes, and quality measures • Health home will need to collect vital signs (pulse, respiratory rate, temperature and blood pressure), height, weight and BMI on a quarterly basis either through primary care provider visit records (annual health checks, acute illness or follow-up visits etc.) and/or appointments with the health home provider (nurse health assessment visit, pharmacological management visits etc.).  • Oxygen saturation level is not a quarterly requirement and it should only be measured as appropriate or needed by the primary care provider or pediatrician. • Example: Patient has an acute or chronic respiratory disease such as asthma, emphysema, COPD or pneumonia, and the primary care doctor is concerned about the low oxygen saturation level.

29. Partner/Provider Outreach and EngagementPage 4 • Attach a copy of your provider outreach plan that you follow to communicate with and engage providers and entities with whom you do not have formal agreements, but with whom you need to develop effective working relationships to serve clients in the health home. • Outreach plan shall address how the health home will educate providers about the health home service, goals and the value of the relationship or collaboration in the delivery of service components, and how and what type of information will be exchanged between the health home provider and the non-health home provider. • Outreach plan shall describe the role of the non-health home provider in coordinating and managing care to the consumer including but not limited to integrated care plan development and revisions and participation in meetings.

30. Partner/Provider Outreach and EngagementPage 5 • (Continued) Attach provider outreach plan. Applicant’s outreach plan must include: • Defined accountabilities for provider outreach and engagement. • Dedicated education and outreach processes and materials. • An accurate and comprehensive description for providers about participating as part of a health home in Ohio: • Reference key components that are included in the planned care model. • Reference goals for integration of physical and behavioral health care. • Acknowledge requirements of the Ohio Rule.

31. Partner/Provider Outreach and EngagementPage 5 • Referencing Table B, applicant should address why and how it will facilitate working relationships with entities listed to ensure that necessary services will be available and/or coordinated for its health home clients as part of their integrated care management. • When you identify a gap in your health home network relationships, describe your strategy to engage and establish effective working relationships.

32. Partner/Provider Outreach and EngagementPage 5 • Table B: Health Home Network Relationships • Please identify those providers that you have or will have relationships, collaborations or partnerships. • Describe how those entities identified are appropriate to serve your health home population (This is answered in # 2 above). • Check all that apply.

33. Consumer Informed Consent and OrientationPage 5 • Attach a copy of your consumer informed consent form and related policies and procedures. • Proposed 5122-29-33 (C)(1)(b) • Document consumer's informed consent specific to enrollment in the health home service prior to enrollment. Informed consent shall include: • Description of the health home service, benefits and drawbacks of enrollment in the health home service, including the relationship between the health home service and other services, particularly other care coordination services (e.g. CPST, MCP care management, AOD case management) • Consumer's ability to opt out of enrollment in the health home service

34. ODMH OAC - 5122-27-04 Consent for treatment still applies, and requires agencies to have in place policies and procedures for obtaining written informed consent for treatment. • Health Home provider must have documentation of informed consent. • It is recommended that the informed consent for the health home service include: • The diagnosis and the other eligibility criteria • The nature and purpose of the health home service • The risks and benefits of the health home service • Alternatives to the health home service • The risks and benefits of not receiving the health home service Health Home ConsumersInformed Consent

35. Consumer Informed Consent and OrientationPage 5 • Attach a copy of your written health home service orientation informational materials. Materials must describe and confirm the process to orient and inform consumers including discussing the benefits of active participation in the health home service.

36. Health Home Orientation • The health home provider must provide the health home member and/or guardian with an orientation that is appropriate for the health home member’s needs and includes the following: • An overview of health home service • The general nature and goals of health home service • An explanation of the consumer’s right to decline services • Information about the hours during which the services are available and how the consumer, family and caregivers may participate in the delivery of health home service • Health home provider must demonstrate orientation of consumers to health home service

37. Comprehensive AssessmentPage 6 • Attach a copy of your health home comprehensive assessment tool(s) [form/template] used to assess an individual’s • physical health • behavioral health (i.e., mental health disorders, substance abuse disorders, and developmental disabilities) • long-term care (e.g., assistance with activities of daily living, functional status, self-care capability), social service needs (e.g., financial assistance, housing, family or support system dynamics). • Refer to the health home application resource document for a list of assessment and planning domains you may use as guidance.

39. Comprehensive AssessmentPage 6 • Attach relevant portions of your policies and procedures that demonstrate you have a plan to initiate assessment and routine updates. This should include such elements as: changes in health status, needs, significant events, system supports and flags for routine updates, i.e., at least every 90 days and annual reassessment. Your response should include the following: • Describe data sources that will be used to complete the comprehensive assessment. • Describe how information from the assessment is used to stratify individuals by categories of risk to develop behavioral, physical and other appropriate health interventions. • Describe your time frames for completing the comprehensive assessment.

40. Care PlanningPage 6 • 1. Attach your integrated care plan template. Care plan components should include: • identification of measurable goals and objectives interventions with specific time frames for completion • provisions for acknowledging client and relevant others’ (i.e., family, guardians, significant others) input, preferences, and level of involvement in the care plan.

41. Care PlanningPage 6 • 2. Attach your policies and procedures which should include: • process for development, review (at least every 90 days) and updating of the integrated care plan • how the care plan addresses and coordinates an individual’s clinical and nonclinical needs.

42. Comprehensive Assessment, Care Planning Dates • Comprehensive Assessment completed within 30 days of enrollment in health home service • Re-assessment at least every 90 days • Integrated Care Plan completed within 60 days of enrollment • Based on results of the comprehensive assessment • Include consumer and family participation • Reviewed at least every 90 days and updated as needed

43. Care CoordinationPage 6 • 1. Describe how you will coordinate with consumer, consumer’s family members and care givers, team members, PCP, specialists, social service and other providers (i.e. tracking tests, referrals, scheduled appointments, follow-up, etc.) in implementing the care plan. Provide the following supporting documents: • Attach your communication protocols or policy that describe information exchange between consumer, consumer’s family members and care givers, team members, PCP, specialists, and other providers. • Attach communication plan to address routine information exchange, ensure that collaboration and communication occurs between consumer, consumer’s family members and care givers, team members, PCP, specialists, other providers and payors.

44. Care Coordination (C)Page 6 • Attach your Crisis Management and Contingency Plan. • Attach your Clinical Summary Report template. • Describe how you will coordinate care (e.g., assist consumer in obtaining health care, including primary, acute and specialty medical care, mental health, substance abuse services and developmental disability services, long-term care and ancillary services; perform medication management, including medication reconciliation; track tests, referrals and follow-up as necessary, etc.)

45. Comprehensive Assessment should include; • Medical, behavioral, long-term care and social service needs • Reassessment of the consumer and review of the existing assessment at least every 90 days • Updates as needed ODMH Mental Health Assessment service standards still apply. • Single Integrated Care Plan should: • Be based on the results of the comprehensive assessment • Include consumer and family participation • Reviewed at least every 90 days • Updated as needed ODMH Individualized treatment plan standards still apply. • Crisis and Contingency Plan should: • Be reflective of assessed clinical need • Communication Plan should: • Be developed for all consumers • Include and be shared with family, significant others, other service and treatment providers Health Home Service ComponentsComprehensive Care

46. Implementation of integrated care plan; • Assist consumer in obtaining health care, including mental health, substance abuse services and developmental disabilities services, ancillary services and supports; • Medication management, including medication reconciliation; • Track tests and referrals and follow-up as necessary; • Coordinate, facilitate and collaborate with consumer, family, team of health care professionals, providers; • Monitor care plan and the individual’s status in relation to his or her care plan goals; • Provide clinical summaries and consumer information along with routine reports of treatment plan compliance to the team of health care professionals, including consumer/family. Health Home Service Components: Care Coordination

47. Health home service provider should share with other providers and implement the following: • Integrated Care Plan • Communication Plan • Crisis and Contingency Plan • Monthly clinical summary reports Health Home Service Components:Care Coordination Highlights

48. Health PromotionPage 7 • Based on the assessed needs of your health home population, describe the following: • How you plan to use consumer-level clinical data to address health promotion programming for an individual’s specific health promotion, self-monitoring and self-care needs and goals (e.g., working with a consumer on his/her individual health promotion goals) • Your systematic strategies to address health promotion for your health home population through programs or initiatives (e.g., evidence-based, evidence-informed, best, emerging and/or promising practices related to smoking cessation, nutrition, chronic disease management, etc.)

49. Provide education to the consumer and his or her family /guardian/significant other that is specific to his/her needs as identified in the assessment; • Assist the consumer to acquire symptom self-monitoring and management skills so that the consumer learns to identify and minimize the negative effects of the chronic illness that interests with his/her daily functioning; • Provide or connect the consumer with the services that promote healthy lifestyle and wellness and are evidence based; • Actively engage the consumer in developing and monitoring the care plan; • Connect consumer with peer supports including self-help/self-management and advocacy groups; • Develop consumer specific self-management plan anticipating possible occurrence or re-occurrences of situations requiring an unscheduled visit to health home or emergency assistance in a crisis; • Population management through use of clinical and consumer data to remind consumers about services need for preventive/chronic care; • Promote behavioral health and good lifestyle choices; • Educate consumer about accessing care in appropriate settings. Health Home Service Components Health Promotion

50. Chronic disease self-management Tobacco cessation Weight management Nutritional counseling Exercise and fitness Preventive services and screenings Health Home Service Components:Health Promotion Highlights