C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.02

Current through 2024-51, December 18, 2024

Subsection 144-101-II-91.02 - GENERAL REQUIREMENTS FOR CCTs AND HOME PROVIDERS

CCTs and HOME Providers shall meet the requirements set forth in this Section.

Both CCTs and HOME Providers shall:

1. Execute a MaineCare Provider Agreement;

2. Complete a CCT application and be approved as a CCT by MaineCare;

3. Have an operational EHR;

4. Participate in Department-required CCT or HOME Provider technical assistance and educational opportunities on an annual basis. At least one (1) person in each CCT and HOME Provider must engage in these opportunities;

5.Meet Core Standards. CCTs and HOME Providers shall demonstrate how they intend to meet the following Core Standards prior to approval to provide services. Within the first three (3) months from the start of the CCTs' and HOME Providers' participation, they shall participate in an on-site assessment initiated by the Department, or its authorized agent, to establish their baseline performance in regards to meeting the Core Standards, and to identify the CCTs' and HOME Providers training and educational needs.

For the remainder of the first year of participation, the CCTs and HOME Providers shall submit quarterly reports on sustained implementation of the Core Standards. After the first year, the CCTs and HOME Providers may request the Department's approval to submit the Core Standard progress report annually instead of quarterly. The progress report shall compare CCT and HOME Providers progress to the baseline.

a.Demonstrated Leadership - CCTs and HOME Providers shall identify at least one individual as a leader within the care team who champions the implementation and continued maintenance of the Core Standards.

b.Team-Based Approach to Care - CCTs and HOME Providers shall implement a team-based approach to comprehensive care management, coordination, and supports that includes expanding the roles of non-billable professionals (e.g. nurses, medical assistants, peer support staff, CHWs, and/or housing navigators). CCTs and HOME Providers shall review policies, procedures, data, and structures to improve care delivery, access, efficiency, and Member engagement in specific ways, including two or more of the following:

i. Identifying roles and responsibilities across care team members;

ii. Training on and integration of non-licensed team professionals as meaningful partners in service delivery;

iii. Holding regular team meetings;

iv. Expanding Member education and support opportunities; and

v. Providing greater data support to enhance the quality and cost-effectiveness of CCT and HOME Providers services.

c.Population Risk Stratification and Management - CCTs and HOME Providers shall adopt processes internally and with external partners (e.g. primary care practices, behavioral health providers, social service agencies) to identify and stratify patients who are at risk for adverse outcomes and shall adopt procedures that direct resources or care processes to reduce those risks. CCTs and HOME Providers shall utilize predictive analytics and/or risk models based on clinical, demographic, social, and/or other model inputs. CCTs and HOME Providers shall retain risk assessment documentation in the Member's record.

"Adverse outcomes" includes, but is not limited to, loss of housing, incarceration, or a negative clinical outcome and/or avoidable use of healthcare services such as crisis services, hospital admissions, and/or emergency department visits.

d.Enhanced Access -The CCTs and HOME Providers shall enhance access to services for their population by:

i. Ensuring access to Member records twenty-four (24) hours a day, seven (7) days a week;

ii. Implementing processes to monitor and ensure access to care, e.g. from referral to intake; and

iii. Following up on Member inquiries within one (1) business day of the Member's inquiry.

e.Integrated Care Management - CCTs and HOME Providers shall have policies and procedures in place to provide care management services for patients at high risk of experiencing adverse outcomes. Care management staff shall have clear roles and responsibilities, receive explicit training to provide care management services, and have processes for tracking outcomes for patients receiving care management services. CCTs and HOME Providers shall contribute to health management strategies and planning processes with their clinical and community partners.

f.Behavioral and Physical Health Integration - Annually, CCTs and HOME Providers shall submit a completed assessment of their Behavioral and Physical Health Integration progress and identify an area of focus for the following twelve-(12) month period to improve Behavioral and Physical Health Integration. The assessment tool will be provided by the Department.

g.Inclusion of Members and Families -CCTs and HOME Providers shall include and document Members and family members as regular participants at leadership meetings or in committees/meetings to advise leadership on patient-centered needs and solutions to improve services.

CCTs and HOME Providers shall implement systems to gather Member and family input at least annually (e.g. via mail survey, phone survey, point of care questionnaires, focus groups, etc.). CCTs and HOME Providers shall have a process in place to design and implement changes that address needs and gaps in care identified via Member and family input.

h.Connection to Community Resources and Social Support Services - CCTs and HOME Providers shall have processes in place to identify local community resources and social support services, including those that provide self-management support to assist Members overcome barriers to care and meet health goals and health-related social needs.

i.Commitment to Reducing Waste, Unnecessary Healthcare Spending, and Improving Cost-effective Use of Healthcare Services - CCTs and HOME Providers shall implement processes to reduce wasteful spending on healthcare resources and to increase the cost-effective use of healthcare services as evidenced by at least one initiative that targets waste reduction from the following list:

i. Reducing avoidable hospitalizations;

ii. Reducing avoidable emergency department visits;

iii. Reducing avoidable escalation of service needs such as crisis, residential, and inpatient stays;

iv. Directing referrals to medical and/or behavioral health specialists who consistently demonstrate and document high quality and cost-efficient use of resources.

j.Integration of Health Information Technology - CCTs and HOME Providers shall use an electronic data system that includes identifiers and utilization data about patients. Member data is used for monitoring, tracking, and indicating levels of care complexity for the purpose of improving patient care.

The system is used to support Member care, including one or more of the following:

i. The documentation of need and monitoring of clinical care;

ii. Supporting implementation and use of evidence-based practice guidelines;

iii. Developing plans of care and related coordination; or

iv. Determining outcomes (e.g. clinical, functional, satisfaction, and cost outcomes); or

v. Assessing risk (e.g. predictive analytics, risk scores/models).

91.02-1Additional Requirements for Community Care Team Providers

1. The CCT shall have a documented relationship (e.g. Memorandum of Understanding or practice agreement) with one or more primary care practices to provide CCT services to patients of the practice; and

2. CCT staff shall consist of a multidisciplinary group of a minimum of three health care professionals and shall cover the roles of a CCT Manager, a Medical Director, and a Clinical Leader. Their responsibilities are:

a. A CCT Manager provides leadership and oversight to ensure the CCT meets Core Standards;

b. A Medical Director (at least 4 hours/month) will collaborate with primary care practices, identify and implement evidenced-based clinical initiatives, lead quality improvement efforts, evaluate progress, and convene clinical quality improvement meetings. The Medical Director shall be a physician (Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)), Advanced Practice Registered Nurse (APRN), or physician assistant; and

c. A Clinical Leader is a clinician who directs care management activities across the CCT and does not duplicate care management that is already in place through primary care providers. The following clinician types may serve as Clinical Leaders: Licensed Clinical Professional Counselor (LCPC); Licensed Clinical Professional Counselor-conditional (LCPC-Conditional); Licensed Clinical Social Worker (LCSW); Licensed Master Social Worker conditional clinical (LMSW-conditional clinical); Licensed Marriage and Family Counselor (LMFT); Licensed Marriage and Family Counselor-conditional (LMFT-conditional); Licensed Alcohol and Drug Counselors (LADC), physician; psychiatrist; APRN; Physician Assistant (PA); registered nurse; licensed clinical psychologist; Certified Clinical Supervisor (CCS); and physician (MD/DO).

The Clinical Leader and Medical Director may be the same individual, but to maintain the minimum of three health care professionals, another team member will need to be included as part of the leadership team.

Additional CCT staff may consist of, but is not limited to, the following: a nurse care coordinator, nutritionist, social worker, behavioral health professional, case manager, pharmacist, care manager or chronic care assistant, CHW (through contracting with a community-based organization (preferred) or employing a CHW directly), care navigator, and/or health coach.

If there is a lapse in staff fulfillment of team member roles of greater than thirty (30) continuous days, the CCT shall notify the Department in writing and maintain records of active recruitment to fill the position(s).

1. The CCT shall maintain a Participant Agreement for data sharing with Maine's statewide state-designated Health Information Exchange (HIE). The minimum clinical data set the CCT shares must include: all patient demographic, encounter, and visit information (including coding) and must be shared via a Health Level - 7 (HL-7) Admission, Discharge & Transfer (ADT) interface

91.02-2Additional Requirements for HOME Providers

1. The HOME Provider shall implement processes, procedures, and Member referral protocols with local primary care providers, behavioral health providers, inpatient facilities, Emergency Departments (EDs), residential facilities, crisis services, and correctional facilities for prompt notification of an individual's admission and/or planned discharge to/from one of these facilities or services. The protocols shall include coordination and communication on enrolled or potentially eligible Members.

2. The HOME Provider shall establish and maintain relationships with shelter services and housing providers to support housing placement and have systematic follow-up protocols to ensure timely access to follow-up care.

3. The HOME Provider shall have a system in place, such as an on-call staff or answering service, for Members to reach a member of the organization or an authorized entity twenty-four (24) hours a day, seven (7) days a week to triage and address the Members' needs.

4. The HOME Provider shall be a community-based or practice-integrated provider with expertise in addressing homelessness. The HOME Provider shall deliver a team-based model of care through a multi-disciplinary team of employed or contracted personnel. The team shall include at least the personnel identified in this sub-section. Unless otherwise specified, each role shall be filled by a different individual; the Department reserves the right to waive this requirement based on team member professional experience and training. If there is a lapse in fulfillment of team member roles of greater than thirty (30) continuous days, the HOME Provider shall notify the Department in writing and maintain records of active recruitment to fill the position(s). All team members shall contribute to delivery of integrated and coordinated, whole-person care through a team-based approach.

a. A HOME Provider Manager is a professional with at minimum a bachelor's degree that provides leadership and oversight to ensure the HOME Provider meets the Core Standards and may be filled by an individual also serving as the Clinical Leader.

b. A Clinical Leader is a clinician who is appropriately licensed or certified, practicing within the scope of that licensure or certification, and qualified to complete and direct the comprehensive assessment and Plan of Care requirements of this Section and directs the care management and coordination activities across the HOME Provider. A clinician includes the following: LCPC; LCPC-conditional; LCSW; LMSW-conditional clinical; LMFT; LMFT- conditional; LADC, physician; psychiatrist; APRN; PA; registered nurse or licensed clinical psychologist; CCS; MD/DO.

c. The Case Manager is a professional who works with the Clinical Leader to implement care management, coordination, and supports to assist the Member gain and maintain access to services to meet the goals of the Plan of Care. The Case Manager shall meet, at minimum, one of the following criteria:

i. Has a minimum of a bachelor's degree in social work, sociology, public health, or nursing from an accredited four (4) year institution of higher learning;

ii. Has a combined five (5) years of education and experience in providing direct services in social, health, or behavior health fields; or

iii. Has a current Mental Health Rehabilitation Technician/Community (MHRT/C) Certification.

d. A Community Health Worker or Peer Support Staff is an individual who has completed one or more of the following:

i. Maine Office of Behavioral Health (OBH) curriculum for Certified Intentional Peer Support Specialist (CIPSS) and receives and maintains that certification.

The CIPSS is an individual who is receiving or has received services and supports related to the diagnosis of a mental illness, is in recovery from that illness, and who is willing to self-identify on this basis with HOME Provider Members. Peer Support Staff may function as a CIPSS without CIPSS certification for the first nine (9) months of functioning as a CIPSS, but may not continue functioning as a CIPSS beyond nine (9) months without:

(a) having received provisional certification by completion of the Core training, and

(b) continuing pursuit of full certification as a CIPSS and maintaining certification as an Intentional Peer Support Specialist according to requirements as defined by OBH;

ii. Connecticut Community for Addiction Recovery (CCAR), or other recovery coach curriculum with certification approved by the Department or their designee in the first six (6) months following their employment start-date with the Home Provider;

iii. HOME Provider organization training to deliver peer support services that includes competencies and training elements focused on supportive housing services and at least one (1) year of full-time equivalent practical work experience related to providing direct support services in the community or behavioral health fields; or

iv. CHW training program with relevant CHW core competencies or evidenced by a Maine CHW certification or registration (effective the date such a designation becomes active in the State of Maine).

Lived experience related to housing insecurity and/or homelessness is preferred for any Peer Support Staff or CHW team members.

e. Housing Navigator is an individual who has completed the Maine State Housing Authority's Housing Navigator training and serves to help the Member find and maintain stable, long-term housing. The Housing Navigator shall help the Member find housing resources, apply for vouchers, establish relationships with area landlords, and related tasks. The Housing Navigator role may be filled by an individual also serving in one of the other roles, as long as the individual also meets the qualifications described above.

f. Additional HOME Provider staff may consist of, but is not limited to, additional Peer Support Staff or CHWs, case workers, care managers, outreach workers, nutritionists, pharmacists, chronic care assistants, social workers, behavioral health professionals, care navigators, or health coaches.

5. The HOME Provider shall adhere to applicable licensing standards regarding keeping documentation of employees' qualifications in their personnel files. Pursuant to applicable licensing standards, the HOME Provider shall have a review process to ensure that employees providing HOME services possess the minimum qualifications set forth above.

6. The HOME Provider shall obtain credential evaluations from a member of the National Association of Credential Evaluation Services (NACES) to ensure that degrees held by staff members and earned from institutions outside of the United States meet the staff qualifications set forth in this sub-section.

7. The HOME Provider shall establish and maintain a relationship with a primary care provider, authorized and evidenced by a signed medical release, for each HOME Provider Member served that has a primary care provider. Such a release is not required when the Member's primary care provider is also the Member's provider within the HOME Provider team. HOME Providers shall work with each Member to establish and/or strengthen primary care relationships.

8. The HOME Provider team shall participate in multi-disciplinary team meetings which include the Member's primary care and behavioral health providers to inform on-going assessment and the Member's Plan of Care, as appropriate.

9. The HOME Provider shall adhere to mandated reporting standards pursuant to Title 22 M.R.S. §4011(A).

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.02