Okla. Admin. Code § 450:17-5-183
Current through Vol. 42, No. 4, November 1, 2024
Section 450:17-5-183 - Care coordination(a) Based on a person and family-centered care plan and as appropriate, the facility will coordinate care for the consumer across the spectrum of health services, including access to physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person. This care coordination shall include not only referral but follow up after referral to ensure that services were obtained, to gather the outcome of those services, and to identify next steps needed.(b) The facility must have procedures and agreements in place to facilitate referral for services needed beyond the scope of the facility. At a minimum, the facility will have agreements establishing care coordination expectations with Federally Qualified Health Centers (FQHCs) and, as applicable, Rural Health Centers (RHCs) to provide healthcare services for consumers who are not already served by a primary healthcare provider.(c) The facility must have procedures and agreements in place establishing care coordination expectations with community or regional services, supports and providers including but not limited to:(3) Juvenile and criminal justice agencies;(4) Department of Veterans Affairs' medical center, independent clinic, drop-in center, or other facility of the Department;(5) Indian Health Service regional treatment centers; and(6) State licensed and nationally accredited child placing agencies for therapeutic foster care services.(d) The facility will develop contracts, memoranda of understanding (MOUs), or care coordination agreements with regional hospital(s), Emergency Departments, Psychiatric Residential Treatment Facilities (PRTF), ambulatory and medical withdrawal management facilities or other system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions and discharges. If, after reasonable effort, the CCBHC is unable to attain contracts, memoranda of understanding (MOUs), or care coordination agreements, the CCBHC will establish written protocols to coordinate care. (1) Transitional care will be provided by the facility for consumers who have been hospitalized or placed in other non-community settings, such as psychiatric residential treatment facilities. The CCBHC will provide care coordination while the consumer is hospitalized as soon as it becomes known. A team member will go to the hospital setting to engage the consumer in person and/or will connect through telehealth as a face to face meeting. Reasonable attempts to fulfill this important contact shall be documented. In addition, the facility will make and document reasonable attempts to contact all consumers who are discharged from these settings within 24 hours of discharge.(2) The facility will collaborate with all parties involved including the discharging/admitting facility, primary care physician, and community providers to ensure a smooth discharge and transition into the community and prevent subsequent re-admission(s).(3) Transitional care is not limited to institutional transitions, but applies to all transitions that will occur throughout the development of the enrollee and includes transition from and to school-based services and pediatric services to adult services.(4) The facility will document transitional care provided in the clinical records.(e) Care Coordination activities shall include use of population health management tools, such as dashboards, patient registries, and team staffings.(f) Care coordination activities will be carried out in keeping with the consumer's preferences and needs for care, to the extent possible and in accordance with the consumer's expressed preferences, with the consumer's family/caregiver and other supports identified by the consumer.(g) The CCBHC shall develop a crisis plan with each person receiving services. At minimum, people receiving services should be counseled about the use of the National Suicide & Crisis Lifeline, 988, local hotlines, mobile crisis, and stabilization services should a crisis arise when providers are not in their office. Crisis plans may support the development of a Psychiatric Advanced Directive, if desired by the consumer. Psychiatric Advance Directives, if developed, must be entered in the electronic health record of the person receiving services so that the information is available to providers in emergency care settings where those electronic health records are accessible.(h) Referral documents and releases of information shall comply with applicable privacy and consumer consent requirements.(i) Compliance with this Section will be determined by on-site observation, review of organizational documents, contracts, MOUs, and clinical records.Okla. Admin. Code § 450:17-5-183
Adopted by Oklahome Register, Volume 33, Issue 23, August 15, 2016, eff. 9/1/2016Amended by Oklahoma Register, Volume 34, Issue 24, September 1, 2017, eff. 10/1/2017Amended by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/15/2021Amended by Oklahoma Register, Volume 40, Issue 22, August 1, 2023, eff. 9/15/2023Amended by Oklahoma Register, Volume 41, Issue 22, August 1, 2024, eff. 9/1/2024