Mo. Code Regs. tit. 9 § 10-7.035

Current through Register Vol. 49, No. 24, December 16, 2024

Section 9 CSR 10-7.035 - Behavioral Health Healthcare Home

PURPOSE: This amendment updates provider qualifications, terminology, and staff requirements and adds complex trauma to the qualifying chronic conditions.

(1) Behavioral Health Healthcare Home Qualifications.

(A) Initial Provider Qualifications. In order to be recognized as a Behavioral Health Healthcare Home, a provider must, at a minimum, meet the following criteria:

1. Have a substantial percentage of individuals served enrolled in Medicaid. Percentage requirements will be determined by the department;

2. Have strong, engaged leadership committed to and capable of leading the organization through the transformation process to Healthcare Home service delivery practices and sustaining those practices as demonstrated through the application process and agreement to participate in learning activities, including in-person sessions and regularly scheduled phone calls as required by the department;

3. Meet the department's minimum access requirements. Prior to implementation of Behavioral Health Healthcare Home service coverage, provide assurance to the department of enhanced access to the care team by individuals served, including the development of alternatives to face-to-face visits, such as telephone or email, twenty-four (24) hours per day, seven (7) days per week;

4. Actively use the department's identified health information technology tool to conduct care coordination, input metabolic syndrome screening results, track and measure care of individuals, automate care reminders, produce exception reports for care planning, and monitor medication adherence;

5. Conduct wellness interventions as indicated based on the individual's level of risk;

6. Complete status reports to document the individual's housing, legal, employment, education, and custody status;

7. Agree to convene regular, ongoing, and documented internal Healthcare Home team meetings to plan and implement goals and objectives of ongoing practice transformation;

8. Agree to participate in department-approved evaluation activities;

9. Agree to develop required reports describing Healthcare Home activities, efforts, and progress in implementing Healthcare Home services;

10. Maintain compliance with all of the terms and conditions as a Behavioral Health Healthcare Home provider or face termination as a provider of Healthcare Home services; and

11. Present a proposed Behavioral Health Healthcare Home service delivery model the department determines will have a reasonable likelihood of being cost effective. Cost effectiveness will be determined based on the size of the proposed Behavioral Health Healthcare Home, Medicaid caseload, percentage of caseload with eligible chronic conditions, and other factors to be determined by the department.

(B) Ongoing Provider Qualifications. Each provider must also-

1. Coordinate care and build relationships with regional hospital(s) or system(s) to develop a structure for transitional care planning, including communication of inpatient admissions of Healthcare Home participants, and maintain a mutual awareness and collaboration to identify individuals seeking emergency department services who might benefit from connection with a Healthcare Home, and encourage hospital staff to notify the area Behavioral Health Healthcare Home staff of such opportunities;

2. Develop quality improvement plans to address gaps and opportunities for improvement identified during and after the application process;

3. Demonstrate continuing development of fundamental Healthcare Home functionality through an assessment process to be determined by the department;

4. Demonstrate significant improvement on clinical indicators specified by and reported to the department;

5. Meet accreditation standards approved by the department; and

6. Provide Behavioral Health Healthcare Home services that demonstrate overall cost effectiveness.

(2) Scope of Services. This section describes the activities behavioral health providers will be required to engage in, and the responsibilities they will fulfill, if recognized as a Behavioral Health Healthcare Home.

(A) Healthcare Home Services. The Healthcare Home Team shall assure the following health services are received, as necessary, by all individuals served in the Behavioral Health Healthcare Home:

1. Comprehensive Care Management. Comprehensive care management includes the following services:

A. Identification of high-risk individuals and use of information obtained during the enrollment process to determine level of participation in care management services;

B. Assessment of preliminary service needs;

C. Development of treatment plans including individual goals, preferences, and optimal clinical outcomes;

D. Assignment of care team roles and responsibilities;

E. Development of treatment guidelines that establish clinical pathways for care teams to follow across risk levels or health conditions;

F. Monitor individual and population health status and service use to determine adherence to, or variance from, treatment guidelines; and

G. Development and dissemination of reports that indicate progress toward meeting outcomes for individual satisfaction, health status, service delivery, and costs;

2. Care Coordination. Care coordination consists of the implementation of the individualized treatment plan through appropriate linkages, referrals, coordination, and follow-up to needed services and supports, including referral and linkage to long-term services and supports. Specific care coordination activities include, but are not limited to:

A. Appointment scheduling;

B. Conducting referrals and follow up monitoring;

C. Participating in hospital discharge processes; and

D. Communicating with other providers and the individual and their family members/natural supports;

3. Health Promotion Services. Services shall minimally consist of health education specific to an individual's chronic conditions, development of self-management plans with the individual, education regarding the importance of immunizations and screenings, child physical and emotional development, providing support for improving social networks, and healthy lifestyle interventions, including but not limited to:

A. Substance use prevention;

B. Smoking prevention and cessation;

C. Nutritional counseling;

D. Obesity reduction and prevention;

E. Increasing physical activity; and

F. Health promotion services also assist individuals in the implementation of their treatment plan and place a strong emphasis on person-centered empowerment to understand and self-manage chronic health conditions;

4. Comprehensive Transitional Care. Members of the care team must provide care coordination services designed to streamline plans of care, reduce hospital admissions, ease the transition to long-term services and supports, and interrupt patterns of frequent hospital emergency department use. Members of the care team collaborate with physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the treatment plan with a specific focus on increasing individuals' and family members' ability to manage care and live safely in the community and shift the use of reactive care and treatment to proactive health promotion and self-management;

5. Individual and Family Support Services. Services include but are not limited to advocating for individuals and families; and assisting with, obtaining, and adhering to medications and other prescribed treatments. Care team members are responsible for identifying resources for individuals to support them in attaining their highest level of health and functioning in their families and in the community, including transportation to medically necessary services. A primary focus will be to help individuals increase their health literacy, self-manage care, and participate in the ongoing revision of their care/treatment plan. For individuals with developmental disabilities (DD), the care team will refer to, and coordinate with, the approved DD case management entity for services more directly related to habilitation or a particular healthcare condition; and

6. Referral to Community and Social Support Including Long-term Services and Supports. This involves providing assistance for individuals to obtain and maintain eligibility for healthcare, disability benefits, housing, personal need, and legal services, as examples. For individuals with DD, the care team will refer to, and coordinate with, the approved DD case management entity for this service.

(B) Healthcare Home Staffing. Behavioral Health Healthcare Home providers will augment their current treatment teams by adding Healthcare Home Director(s), Specialized Healthcare Consultant(s), and Nurse Care Manager(s) to provide consultation as part of the care team and assist in delivering Healthcare Home services. Care Coordinator(s) will also be funded to assist with Healthcare Home supporting functions.

(C) Learning Activities. Behavioral health providers will be supported in transforming service delivery by participating in statewide learning activities. Providers will participate in a variety of learning supports, up to and including learning collaboratives specifically designed to demonstrate how to operate as a Behavioral Health Healthcare Home and provide care using a whole person approach that integrates behavioral health, primary care, and other needed services and supports. Learning activities will be supplemented with periodic calls to reinforce the learning sessions, practice coaching, and monthly practice reporting (data and narrative) and feedback.

1. Learning activities will support Behavioral Health Healthcare Home providers in addressing the following:

A. Providing quality-driven, cost-effective, culturally-appropriate, and person- and family-centered healthcare home services;

B. Coordinating and providing access to high-quality healthcare services informed by evidence-based clinical practice guidelines;

C. Coordinating and providing access to preventive and health promotion services, including prevention of mental illness and substance use disorders;

D. Coordinating and providing access to mental health and substance use disorder treatment services;

E. Coordinating and providing access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate followup from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of healthcare;

F. Coordinating and providing access to chronic disease management, including self-management support to individuals and their families;

G. Coordinating and providing access to individual and family supports, including referral to community, social support, and recovery services;

H. Coordinating and providing access to long-term care supports and services;

I. Developing a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical healthcare related needs and services;

J. Demonstrating a capacity to use health information technology to link services, facilitate communication among team members and between the care team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and

K. Establishing a continuous quality improvement program and collecting and reporting on data that permits an evaluation of increased coordination of care and chronic disease management on individual level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level.

(D) Patient Registry. Behavioral Health Healthcare Homes shall utilize the patient registry approved by the department. A patient registry is a system for tracking information the department deems critical to the management of the health of the population being served through a Healthcare Home, including dates of delivered and needed services, laboratory values needed to track chronic conditions, and other measures of health status. The registry shall be used for-

1. Tracking;

2. Risk stratification;

3. Analysis of population health status and individual needs; and

4. Reporting as specified by the department.

(E) Data Reporting. Behavioral Health Healthcare Homes shall submit the following reports to the department as specified:

1. Monthly updates identifying the Behavioral Health Healthcare Home's staffing patterns, enrollment status, hospital follow-ups, and notifications provided to primary healthcare providers; and

2. Other reports as specified by the department.

(F) Demonstrated Evidence of Healthcare Home Transformation. Providers are required to demonstrate evidence of transformation to the Behavioral Health Healthcare Home model on an ongoing basis using measures and standards established by the department and communicated to the providers. Transformation to the Behavioral Health Healthcare Home service delivery model is exhibited when a provider-

1. Demonstrates development of fundamental Healthcare Home functionality at six (6) months and twelve (12) months based on an assessment process determined by the department. Providers must demonstrate continued improvement and functionality for as long as they maintain their Behavioral Health Healthcare Home designation; and

2. Demonstrates improvement on clinical indicators specified by and reported to the department.

(G) Participation in Evaluation. Providers shall participate in ongoing evaluation. Participation may entail responding to surveys and requests for interviews with Behavioral Health Healthcare Home staff and individuals served. Providers shall provide all requested information to the evaluator in a timely fashion.

(H) Notification of Staffing Changes. Providers are required to notify the department within five (5) working days of staff changes in any of the Healthcare Home staff positions referenced in subsection (2)(B) of this rule.

(I) Providers shall work cooperatively with the department to support approved training, technology, and administrative services required for ongoing implementation and support of the Behavioral Health Healthcare Homes.

(3) Patient Eligibility and Enrollment. This section describes eligibility and enrollment requirements for Behavioral Health Healthcare Homes.

(A) Individuals receiving Medicaid benefits must meet one (1) of the following criteria to be eligible for services from a designated Behavioral Health Healthcare Home:

1. Be diagnosed with a serious and persistent mental health condition (adults with Serious Mental Illness (SMI) and children with Severe Emotional Disturbance (SED)); or

2. Be diagnosed with a mental health condition and substance use disorder; or

3. Be diagnosed with a mental health condition and/or substance use disorder, and one (1) other chronic condition including diabetes, chronic obstructive pulmonary disease (COPD), asthma, cardiovascular disease, overweight (body mass index (BMI) > 25), tobacco use, developmental disability, or complex trauma.

(B) Providers may determine enrollment in the Behavioral Health Healthcare Home for individuals being served within their organization who meet eligibility requirements in accordance with the following:

1. Enrollment is based on the choice of individuals served; and

2. Individuals may choose not to enroll in the Behavioral Health Healthcare Home or may choose another provider's Behavioral Health Healthcare Home if one exists in their area.

(C) Behavioral Health Healthcare Homes must follow Healthcare Home enrollment procedures, including submittal of the required Healthcare Home enrollment form(s).

(4) Healthcare Home Payment Components. This section describes the payment process for Behavioral Health Healthcare Homes.

(A) General.

1. All payments to a Behavioral Health Healthcare Home are contingent on the site meeting the Behavioral Health Healthcare Home requirements set forth in this rule. Failure to meet these requirements is grounds for revocation of a site's designation as a Behavioral Health Healthcare Home and for termination of payments specified within this rule.

2. Reimbursement for Healthcare Home services will be in addition to a provider's existing reimbursement for services and procedures and will not change existing reimbursement for services and procedures that are not part of the Behavioral Health Healthcare Home.

3. The department reserves the right to make changes to the payment methodology.

(B) Types of Payments.

1. Clinical Care Management Per Member Per Month (PMPM). PMPM reimburses for the cost of staff primarily responsible for delivery of Behavioral Health Healthcare Home services not covered by other reimbursement and whose duties are not otherwise reimbursable by Medicaid.

9 CSR 10-7.035

Adopted by Missouri Register February 15, 2019/Volume 44, Number 4, effective 4/1/2019

Amended by Missouri Register December 1, 2023/volume 48, Number 23, effective 1/30/2024.