CCTs and HOME Providers shall meet the requirements set
forth in this Section.
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).
91.02-1
Additional 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
91.02-2
Additional
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).
