A. The BHHO must
execute a MaineCare Provider Agreement.
B. The BHHO must be approved as a BHHO by
MaineCare through the BHHO application process.
C. The BHHO must be a community-based mental
health organization, licensed to provide services in the state of Maine, that
provides case management to adult and/or children members, is located in the
state of Maine, and delivers services through a team-based model of care that
includes at least the following personnel.
The Department shall seek and
anticipates receiving CMS approval for this Section. Pending approval,
each role must be filled by a different individual. If there is a lapse in
fulfillment of team member roles of greater than thirty (30) continuous days,
the BHHO must notify the Department in writing and maintain records of active
recruitment to fill the position(s).
(1)
Psychiatric Consultant -shall be a psychiatrist who has current
and valid licensure as a physician from the Maine Board of Licensure in
Medicine, and who is certified by the American Board of Psychiatry and
Neurology Psychiatric medication management or is eligible for examination by
that Board as documented by written evidence from the Board, or has completed
three (3) years of post-graduate training in psychiatry approved by the
Education Council of the American Medical Association and submits written
evidence of the training; OR a psychiatric and mental health advanced practice
registered nurse (PMH-APRN) who is licensed as a nurse practitioner or clinical
nurse specialist by the state of Maine, has graduated from a child and
adolescent or adult psychiatric and mental health nurse practitioner, or
clinical nurse specialist program, and is certified by the appropriate national
certifying body.
The Psychiatric Consultant shall consult with other BHHO
and primary care professionals and with the member as necessary, to provide
expertise on the development of evidence-based practices and protocols to the
BHHO organization.
Under Section
92, the Psychiatric Consultant
shall not duplicate any other psychiatric services that may be necessary and
provided through other sections of the MaineCare Benefits
Manual.
(2)
Nurse Care Manager - shall be a registered nurse, a psychiatric
nurse licensed as a registered professional nurse by the state where services
are provided and certified by the American Nurses Credentialing Center (ANCC)
as a psychiatric and mental health nurse; a PMH-APRN who is licensed as a nurse
practitioner or clinical nurse specialist by the state where services are
provided, who has graduated from a child and adolescent or adult psychiatric
and mental health nurse practitioner or clinical nurse specialist program, and
is certified by the appropriate national certifying body; or an advanced
practice nurse, as defined by the Maine State Board of Nursing.
The Nurse Care Manager shall provide primary care
consultation, psychiatric care consultation, and work with the BHHO, the
primary care practice and the member to provide other Section
92 services as necessary, pursuant
to the Plan of Care.
(3)
Clinical Team Leader - shall be an independently licensed mental
health professional, who may be a physician, physician's assistant,
psychologist, a licensed clinical social worker, licensed master social worker
conditional II licensed clinical professional counselor, licensed marriage and
family therapist, advanced practice registered nurse such as a PMH-APRN; OR,
for children's BHH services, a person who was employed on August 1, 2009 as a
case management supervisor under the former Section
13 of Chapter II of the
MaineCare Benefits Manual.Such staff shall be considered
qualified to serve as a Clinical Team Leader for purposes of this rule.
The Clinical Team Leader shall oversee the development of
the Plan of Care and direct care management activities across the BHHO, provide
supervision of Health Home Coordinators and Certified Intentional Peer Support
Specialists, and ensure that the BHHO meets its requirements as a whole.
(4)
Certified Intentional
Peer Support Specialist (CIPSS) - (for adult services) is an individual
who has completed the Maine Office of Behavioral Health (OBH) curriculum for
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 BHH 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 SAMHS.
The CIPSS shall coordinate and provide access to Peer
Support Services, peer advocacy groups, and other peer-run or peer-centered
services, maintain updated information on area peer services, and shall assist
the member with identifying and developing natural support
systems.
(5)
Family or Youth Support Specialist - (for children's services) is
an individual who has completed a designated Maine Office of Child and Family
Services (OCFS) curriculum for peer supports and receives and maintains that
certification. The Youth Support Specialist 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 BHH members.
The Family Support Specialist is an individual who has a
family member who is receiving or has received services and supports related to
the diagnosis of a mental illness, and who is willing to self-identify on this
basis with BHH members. Peer support staff may function as a Family/Youth
Support Specialist for children's services without certification for the first
nine (9) months of functioning as a Family/Youth Support Specialist, but may
not continue functioning as a Family/Youth Support Specialist for children's
services beyond nine months:
(a)
without having received provisional certification by completion of the Core
training, and
(b) without
continuing pursuit of full certification as a Family/Youth Support Specialist
for children's services and maintaining certification as a Family/Youth Support
Specialist according to requirements as defined by OCFS.
(6)
Health Home Coordinator for Members
with Serious Emotional Disturbance (SED) -shall be an individual who has
a minimum of a Bachelor's Degree from an accredited four (4) year institution
of higher learning, with specialization in psychology, mental health and human
services, behavioral health, behavioral sciences, social work, human
development, special education, counseling, rehabilitation, sociology, nursing,
or closely related field; OR who has a Bachelor's Degree from an accredited
four (4) year educational institution in an unrelated field and at least one
(1) year of full-time equivalent relevant human services experience; OR a who
has Master's Degree in social work, education, psychology, counseling, nursing,
or closely related field from an accredited graduate school; OR who has been
employed since August 1, 2009 as a case manager providing services under
Chapter II, Section
13 of the
MaineCare
Benefits Manual.
The SED Health Home Coordinator shall draft the Plan of
Care for each SED member utilizing a Child and Adolescent Needs and Strengths
assessment tool (CANS) information, implement that Plan of Care and the
coordination of services, and support and encourage members inactively
participating in reaching the goals set forth in their Plan of Care.
Each member shall have only one Health Home Coordinator
and cannot be enrolled in more than one case management program funded by
Medicaid.
(7)
Health
Home Coordinator for Members with Serious and Persistent Mental Illness
(SPMI) - shall be an individual who is certified by the Department as a
Mental Health Rehabilitation Technician/Community (MHRT/C).
The SPMI Health Home Coordinator shall draft the Plan of
Care for each member, oversee that Plan of Care and the coordination of
services, and support and encourage members in actively participating in
reaching the goals set forth in their Plan of Care.
Each member shall have only one Health Home Coordinator
and cannot be enrolled in more than one case management program funded by
Medicaid.
(8)
Medical
Consultant - shall be a physician licensed by the State of Maine to
practice medicine or osteopathy, a physician's assistant licensed as such by
the State of Maine, or a certified nurse practitioner who meets all of the
requirements of the licensing authority of the State of Maine.
The Medical Consultant shall collaborate with other
providers of BHHO and primary care services (at least 4 hours/month per 200
members or pro-rated for agencies that serve fewer than 200 clients) to select
and implement evidence-based clinical initiatives, lead quality improvement
efforts, evaluate progress, and convene provider clinical quality improvement
meetings.
D. The
BHHO must a there to licensing standards in documentation of all its BHHO
providers' qualifications in their personnel files. Pursuant to applicable
licensing standards, the BHHO must have a review process to ensure that
employees providing BHHO services possess the minimum qualifications set forth
above.
E. The BHHO must be
co-occurring capable, meaning that the organization is structured to welcome,
identify, engage and serve individuals with co-occurring substance use and
mental health disorders and to incorporate attention to these issues into
program content.
F. The BHHO must
have an executed contract or Memorandum of Agreement with at least one (1) HHP
in its area that describes procedures and protocols for regular and
systematized communication and collaboration across the two agencies, the roles
and responsibilities of each organization in service delivery, and other
information necessary to effectively deliver, pay and receive reimbursement for
all BHH services to all shared members without duplication. This may include
names and contact information of key staff at the BHHO and HHP, acceptable
mode(s) of electronic communication to ensure effective and privacy-protected
exchange of health information, frequency of communication at both leadership
and practice levels (e.g., weekly, monthly, quarterly), procedures for
bi-directional access to member Plan of Care and other health information,
referral protocols for new members, collaboration on treatment plans and member
goals and, as needed, Business Associate Agreement/Qualified Service
Organization addenda.
G. The BHHO
musthavean EHR system and an EHR for each member.
H. The BHHO shall have in place processes,
and procedures, and member referral protocols with local inpatient facilities,
Emergency Departments (ED), child/adult residential facilities, crisis
services, and corrections for prompt notification of an individual's admission
and/or planned discharge to/from one of these facilities or services. The
protocols must include coordination and communication on enrolled or
potentially eligible members, The BHHO shall have systematic follow-up
protocols to assure timely access to follow-up care.
I. The BHHO shall ensure that it has policies
and procedures in place to ensure that the Health Home Coordinator can
communicate changes in patient condition that may necessitate treatment change
with treating clinicians, on an as needed basis.
J. The BHHO must participate in BHH technical
assistance opportunities, as determined by the Department. At least one (1)
member of the care team described in 92.02-1(C) must engage in these
opportunities.
K. Within the first
six (6) months following the start of the BHHO's participation, the BHHO shall
obtain a written site assessment from the Department or its authorized entity,
to establish a baseline status in meeting the Core Standards (92.02-1 (L)) and
identify the BHHO's training and educational needs.
L. For the first year of participation, the
BHHO must submit quarterly reports on progress towards implementing the Core
Standards. Within one year of the BHHO's participation, the BHHO must fully
implement the Core Standards.
Once Core Standards are fully implemented, the BHHO may
request the Department's approval to submit the Core Standard progress report
annually instead of quarterly.
The Core Standards are:
(1)
Demonstrated Leadership -
The BHHO identifies at least one (1) Clinical Team Leader within the BHHO who
implements and oversees the Core Standards.
The Clinical Team Leader(s) work with other providers and
staff in the BHHO to build a team-based approach to care, continually examine
the processes and structures to improve care, and review data on the
performance of the BHHO.
(2)
Team-Based Approach to Care - The BHHO has implemented a
team-based approach to care delivery that includes expanding the roles of
non-licensed team professionals and includes CIPSS as leaders and partners in
the provision of care.
The BHHO utilizes non-licensed staff to improve access,
efficiency, and member engagement in specific ways, including one or more of
the following:
(a) Through clear
identification of roles and responsibilities;
(b) Training on and integration of CIPSS as
meaningful partners in service delivery;
(c) Regular team meetings.
(3)
Population Risk
Stratification and Management - The BHHO has adopted processes to
identify and stratify members across their population who are at risk of
adverse outcomes and adopted procedures that direct resources or care processes
to reduce those risks.
For purposes of this provision, "adverse outcomes" means
hospitalization, institutionalization, involvement with law enforcement, job
loss or home loss, which occur as a result of the member's SPMI or SED.
(4)
Enhanced Access -
The BHHO enhances access to services for their members, including:
(a) The BHHO has a system in place, such as
an on call or answering service, for BHH members to reach a member of the
organization or an authorized entity twenty-four (24) hours a day, seven (7)
days a week to address and triage the members' needs.
(b) The BHHO has processes in place to ensure
twenty-four (24) hours a day, seven (7) days a week access to BHH member
records.
(c) The BHHO has processes
in place to monitor and ensure this enhanced access to care.
(5)
Comprehensive
Consumer/Family Directed Care Planning - The BHHO has processes in place
to ensure that consumer voice and choice is reflected in Plan of Care
development. These processes include:
(a)
Wraparound principles for children with SED and their families.
(b) Practice guidelines for recovery-oriented
care.
(6)
Behavioral-Physical Health Integration - The BHHO has completed a
baseline assessment of its behavioral-physical health integration capacity
during its first year of participation as a BHHO. Using results from this
baseline assessment, the BHHO has implemented one or more specific improvements
to integrate behavioral and physical health care.
(7)
Inclusion of Members and
Families - The BHHO includes members and their family as documented and
regular participants at leadership meetings, and/or the BHHO has in place a
member-driven process to identify needs and solutions for improving services.
(a) The BHHO has processes in place to
support members and families to participate in these leadership and/or advisory
activities (e.g., on the agency's Board of Directors, involvement in internal
advisory committees that solicit and support the engagement of consumers and
families in identifying needs and solutions, etc.);
(b) The BHHO has implemented systems to
gather member and family input at least annually (through mail surveys, phone
surveys, point of care questionnaires, focus groups, or other methods);
and
(c) The BHHO has processes in
place to design and implement changes that address needs and gaps in care
identified via member and family input.
(8)
Connection to Community Resources
and Social Support Services - The BHHO has processes in place to
identify and make referrals to local community resources and social support
service, including those that provide support in self-management, to assist
members in overcoming barriers to care and meeting health and recovery
goals.
(9)
Commitment to
Reducing Waste, Unnecessary Healthcare Spending, and Improving Cost-Effective
Use of Healthcare Services - The BHHO has processes in place to reduce
wasteful spending of healthcare resources and improving the cost-effective use
of healthcare services, as evidenced by at least one initiative that targets
waste reduction, such as:
(a) Reducing
avoidable hospitalizations;
(b)
Reducing avoidable ED visits;
(c)
Working with specialists to develop new models of specialty consultation that
improve member experience and quality of care, while reducing unnecessary use
of services; and
(d) Directing
referrals to specialists who consistently demonstrate high quality and
cost-efficient use of resources.
(10)
Integration of Health Information
Technology - The BHHO uses an electronic data system that includes
identifiers and utilization data about members. Member data is used for
monitoring, tracking and indicating levels of care complexity for the purpose
of improving member care.
The system is used to support member care, including one
or more of the following:
(a) The
documentation of need and monitoring clinical care
(b) Supporting implementation and use of
evidence-based practice guidelines;
(c) Developing Plans of Care and related
coordination; and
(d) Determining
outcomes (e.g., clinical, functional, recovery, satisfaction, and cost
outcomes).
