C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-92, subsec. 144-101-II-92.05

Current through 2024-44, October 30, 2024

Subsection 144-101-II-92.05 - COVERED SERVICES

BHH services may be delivered face-to-face, via phone or other media, in any community location where confidentiality can be maintained. Not all aspects of BHH covered services require direct member involvement; however, all covered services require that provider activities are directly related to an individual member, are member-informed, and pursuant to the member's Plan of Care. BHH covered services are services provided by the BHHO and HHP as follows.

92.05-1Comprehensive Care Management

Comprehensive Care Management are services provided to assure that members receive timely and coordinated services and supports that address physical and behavioral health needs, and promote community and home-based recovery.

A.Comprehensive Care Management Services - BHHO :

(1)Comprehensive Assessment. Within the first thirty (30) days following a member's enrollment for BHH services, the Health Home Coordinator, in consultation with other providers, as necessary, shall provide each member with a face-to-face meeting and a comprehensive assessment that identifies the medical, behavioral, mental health, social, residential, educational, vocational, and other related needs, strengths, and goals of the member (and the family/caretaker if the member is a minor), including utilization of screening tools for co-occurring disorders. The comprehensive review shall include a psychosocial assessment, including history of trauma and abuse, substance use, general health and capabilities, medication needs, member strengths and how they can be optimized to promote goals, available support systems, living situation, employment and/or educational status, and other relevant information. A reassessment must occur as change in the member's needs warrants or at a minimum on an annual basis.

(2)Plan of Care .Based on the comprehensive assessment, within the first thirty (30) calendar days following a member's enrollment, the Health Home Coordinator in partnership with the member, shall draft a comprehensive, individualized, and member-driven Plan of Care that shall identify and integrate behavioral and physical health needs and goals. The BHHO shall be responsible for the management, oversight, and implementation of the Plan of Care, including ensuring active member participation and that measurable progress is being made on the goals identified in the Plan of Care.

(a) The Plan of Care must be consented to by the member, as reflected by the member's signature on the Plan of Care, documented in the member's record, and accessible to the member, the BHHO, HHP and other providers, as appropriate.

(b) The BHHO shall obtain written consent for services and authorization for release and sharing of information from each member.

(c) The Plan of Care may include, but not be limited to, information on prevention, wellness, peer supports, health promotion and education, crisis planning, and identifying other social, residential, educational, vocational, and community services and supports that enable a member to achieve physical and behavioral health goals.

(d) The member (or parent/guardian) plays a central and active role in the development and maintenance of the Plan of Care, which shall clearly identify the goals and timeframes for improving the member's health and health care status, and the interventions that will produce this effect.

(e) If authorized by the member, the BHHO shall document in the Plan of Care the member's family, guardian(s), or caregiver support systems and preferences. If authorized by the member, the Plan of Care shall be accessible to the member's family, guardian(s), or other caregivers.

(f) The Plan of Care shall identify member strengths and how these strengths can be optimized to promote goals.

(g) The Plan of Care shall clearly identify providers involved in the member's care, such as the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), Health Home Coordinator, and other providers directly involved in the member's care.

(h) All identified clinical services indicated in the Plan of Care must be approved by a medical or mental health professional working within the scope of his/her license.

(i) The Plan of Care must be reviewed and approved in writing by a medical or mental health professional within the first thirty (30) calendar days following acceptance of the Plan by the member, and every ninety (90) calendar days thereafter, or more frequently if indicated in the Plan of Care. The Health Home Coordinator with other care team members, as appropriate, shall review the Plan of Care as changes in the member's needs occur, or at least every ninety (90) days, to determine the efficacy of the services and supports, and formulate changes in the Plan as necessary, with member consultation.

(j) The BHHO shall consult with care team members and the member as necessary, and update the Plan accordingly to ensure that it remains current.

(k) The member may decline to receive services identified in the Plan of Care, in which case the BHHO must document such declination in the member's record.

(3)Integration with Primary Care. During the first three (3) months after a member's enrollment, the BHHO shall provide individualized outreach, education and support to the member (and family, if the member is a minor) regarding BHHO services and benefits, including information on sharing personal health information, and coordination with primary care services. These services may be provided via in-person meetings, follow up phone calls, development of written materials or presentations, assistance from Peer Support providers, and other strategies to ensure that the BHHO's members are fully educated and engaged with the needs and goals set forth in the Plan of Care.

(4) The BHHO shall scan for gaps in each member's care by reviewing, at a minimum, utilization reports for data across the following domains, and work with the member and appropriate providers to address any gaps in care:

(a) Hospitalizations in the last quarter as well as the last year;

(b) ED visits in the last quarter as well as the last year;

(c) Patients with total paid claims greater than $10,000;

(d) Patients with eleven (11) or more medications;

(e) Patients with no PCP visits in the last year;

(f) Patients with no HbA1c test (diabetes) in the last quarter;

(g) Patients with no LDL panel (diabetes) in the last year; and

(h) Patients with no LDL panel in the last year (CVD).

B.Comprehensive Care Management Services - HHP :

(1) The HHP shall coordinate with the member and the BHHO in the development of the Plan of Care and ensure that current medical information regarding all physical health conditions, including lab tests/results, and medications, are shared and incorporated in the Plan of Care.

(2) The HHP shall conduct clinical assessment, monitoring and follow up of physical and behavioral health care needs, conduct medication review and reconciliation, monitor chronic conditions, weight/BMI, tobacco and other substance use, and communicate regularly with the BHHO and other treatment providers, as necessary, to identify and coordinate a member's emerging care management needs.

Specifically, HHPs shall have processes in place to conduct the following screenings and assessments for all of their assigned BHH members:

(a) Measurement of BMI in all adult patients at baseline and at least every two years, and BMI percent-for-age at least annually in all children.

(b) During the second year of MaineCare participation as a Health Home practice and annually thereafter:

(c) Depression and substance use screening (PHQ9 and AUDIT, DAST) for all adults with chronic illness, and substance use screening (CRAFFT) for adolescents.

(d) ASQ or PEDS developmental screening for all children age one to three, and the MCHAT 1 for at least one screening between ages 16-30 months with a follow-up MCHAT 2 if a child does not pass the screening test.

(3) The HHP shall scan for gaps in each member's care by, at a minimum, reviewing utilization reports for data across the following domains, and work with the BHHO and the member to address any gaps in care:

(a) Hospitalizations in the last quarter as well as the last year;

(b) ED visits in the last quarter as well as the last year;

(c) Patients with total paid claims greater than $10,000;

(d) Patients with eleven (11) or more medications;

(e) Patients with no PCP visits in the last year;

(f) Patients with no HbA1c test (diabetes) in the last quarter;

(g) Patients with no LDL panel (diabetes) in the last year; and

(h) Patients with no LDL panel in the last year (CVD).

92.05-2Care Coordination

Care Coordination is a set of services designed to support the member (and family/guardian if the member is a minor) in the implementation of the Plan of Care.

A.Care Coordination Services - BHHO

(1) For each member, the BHHO shall identify specific resources and the amount, duration, and scope of services necessary to achieve the goals identified in the Plan of Care. The BHHO shall provide referrals to other services and supports, as identified in each member's Plan of Care, and shall follow up with each member to ensure that the member takes action in regard to each referral.

(2) The BHHO shall have an organizational understanding and provide systematic identification of local medical, community, and social services and resources that may be needed by the member.

(3) The BHHO shall assign to each member a Health Home Coordinator, who shall be responsible for overall management of the Plan of Care, and coordinate and provide access to other providers, including the HHP, as set forth in the Plan of Care.

(4) The BHHO shall ensure that members have access to crisis intervention and resolution services, coordinate follow up services to ensure that a crisis is resolved, and assist in the development and implementation of crisis management plans. Unless other resources are preferred by the member, crisis services are DHHS-funded crisis providers in the community.

(5) The BHHO shall coordinate and facilitate access to psychiatric consultation and/or medication management.

B.Care Coordination Services - HHP: For each member, the HHP shall coordinate and provide access to high quality physical health and treatment services identified in the Plan of Care, including the identification and referral to physical health care specialty providers. The HHP shall consult and coordinate with the BHHO to facilitate successful referral to all necessary services and supports identified in the Plan of Care.

92.05-3Health Promotion

Health Promotion is a set of services that emphasize self-management of physical and behavioral health conditions, in an effort to assist the member in the implementation of the Plan of Care.

A.Health Promotion Services - BHHO

(1) The BHHO shall provide education, information, training and assistance to members in developing self-monitoring and management skills.

(2) The BHHO shall promote healthy lifestyle and wellness strategies, including but not limited to: substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention, and increasing physical activities.

(3) The BHHO shall coordinate and provide access to self-help/self-management and advocacy groups, and shall implement population-based strategies that engage members about services necessary for both preventative and chronic care. For members who are minors, the BHHO shall provide training to the member's parent/guardian in regard to behavioral management and guidance on at-risk behavior.

B.Health Promotion Services - HHP

(1) The HHP shall coordinate with the member and the BHHO to identify and provide access to necessary Health Promotion Services, based on each member's needs, as set forth in the Plan of Care, including providing education about the management of chronic physical conditions.

(2) The HHP shall review all discharge plans, monitor and review medication and lab results, and regularly communicate about these efforts with the BHHO.

92.05-4Comprehensive Transitional Care

Comprehensive Transitional Care services are designed to ensure continuity and coordination of care, and prevent the unnecessary use of the ED, hospitals, and/or out of the home placement of members.

A.Comprehensive Transitional Care Services - BHHO

(1) The BHHO shall collaborate with facility discharge planners, the member and the member's family or other support system, as appropriate, to ensure a coordinated, safe transition to the home/community setting, and to prevent avoidable readmission after discharge.

(2) The BHHO shall assist the member with the discharge process, including outreach in order to assist the member with returning to the home/community.

(3) The BHHO shall follow up with each member following a hospitalization, use of crisis service, or out of home placement.

(4) The BHHO shall collaborate with members, their families, and facilities to ensure a coordinated, safe transition between different sites of care, or transfer from the home/community setting into a facility.

(5) The BHHO shall assist the member in exploration of less restrictive alternatives to hospitalization/institutionalization.

(6) The BHHO shall provide timely and appropriate follow up communications on behalf of transitioning members, which includes a clinical hand off, timely transmission and receipt of the transition/discharge plan, review of the discharge records, and coordination of medication reconciliation.

(7) The BHHO shall facilitate, coordinate, and plan for the transition of members from children's services to the adult system.

B.Comprehensive Transitional Care Services - HHP

(1) The HHP shall review any and all discharge plans and timely follow up with the member regarding physical health needs, including medication reconciliation, consult with the BHHO regarding same, and update the member's Plan of Care accordingly.

92.05-5Individual and Family Support Services

Individual and family support services include assistance and support to the member and/or the member's family in implementing the Plan of Care.

A.Individual and Family Support Services - BHHO

(1) The BHHO shall provide assistance with health-system navigation, and training on self-advocacy techniques.

(2) In accordance with the members Plan of Care, the BHHO shall provide information, consultation, and problem-solving supports, if desired by a member, to the member, and his or her family or other support system, in order to assist the member in managing symptoms or impairments of his or her illness.

(3) The CIPSS shall coordinate and provide access to Peer Support Services, Peer advocacy groups, and other Peer-run or Peer-centered services, and shall assist the member with identifying and developing natural support systems.

(4) The BHHO shall discuss advance directives with members and their family, guardian(s), or caregivers, as appropriate.

(5) The BHHO shall assist the member in developing communication skills necessary to request assistance or clarification from supervisors and co-workers when needed and in developing skills to enable the individual to maintain employment.

B.Individual and Family Support Services - HHP : The HHP shall assist the member with medication and treatment management and adherence, and shall document such efforts in the member's EHR.

92.05-6Referral to Community and Social Support Services

Referral to Community and Social Support Services involves providing assistance to members to obtain and maintain diverse services and supports as identified in their Plan of Care. Referral to community and social services involves an organizational understanding and systematic identification of area resources, services and supports

A.Referral to Community and Social Support Services - BHHO

(1) Services may include outreach and coordination by providers, as needed to ensure a successful referral, and may include reminders and scheduling appointments.

(2) The BHHO will also provide linkages to services, including linkages to long-term care services and home and community supports.

B.Referral to Community and Social Support Services - HHP. Clinical staff at the HHP may provide referrals to community and social supports.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-92, subsec. 144-101-II-92.05