The OHH must meet the following requirements. OHH
providers must maintain documentation of all processes and procedures described
below in an operating manual that is available for review by the Department
upon request.
93.02-1
Opioid
Health Home (OHH) Requirements
A. The
OHH must execute a MaineCare Provider Agreement. The OHH is subject to
applicable state and federal Medicaid law, including but not limited to the
MBM, Chapter I, Section 1.
B. The
OHH must be approved as an OHH by the Department through the OHH application
process.
C. The OHH is encouraged
to utilize an EHR system and create an EHR for each member. Lack of an EHR
system will not be a determining factor in approving an OHH provider
application.
D. The OHH 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
member services.
E. The OHH must be
a community-based provider located within the state of Maine. The OHH delivers
a team-based model of care through a team of employed or contracted personnel.
The team must include at least the personnel identified in this sub-section.
Unless otherwise specified, each role must 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 OHH must
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.
1.
Clinical Team
Lead - A licensed clinical professional with significant experience
treating individuals with substance use disorders, who may be a physician,
physician's assistant, psychologist, Licensed Clinical Social Worker (LCSW),
Licensed Clinical Professional Counselor (LCPC), Licensed Alcohol and Drug
Counselor - Certified Clinical Supervisor (LADC-CCS) or Advanced Practice
Registered Nurse (APRN).
The Clinical Team Lead shall coordinate the care
management activities across the OHH, ensure that there is a current Plan of
Care/ITP for each member, and ensure that there is appropriate supervision of
the Recovery Coach.
The Clinical Team Lead role may be filled by an
individual also serving in one of the other roles below, as long as the
individual also meets the qualifications described above.
2.
MOUD prescriber - A licensed
health care professional with authority to prescribe buprenorphine.
OHH MOUD prescribers provide services for the chronic
condition of opioid dependence through an office-based opioid treatment setting
and shall be trained and authorized to prescribe buprenorphine, buprenorphine
derivatives, and naltrexone for opioid dependence.
OHH MOUD prescribers must have completed any applicable
federally required training and hold the appropriate X-DEA license to prescribe
buprenorphine in an office-based setting. They are required to adhere to
Maine's Office of Substance Abuse and Mental Health Services, 14-118 C.M.R.
Chapter 11, Rules Governing the Controlled Substances Prescription
Monitoring Program and Prescription of Opioid Medications.
For members in the Methadone Level of Care who receive
OHH services from an OTP, this role may be filled by a practitioner licensed
under state and federal law to order, administer, or dispense opioid agonist
treatment medications.
For members in the Methadone Level of Care who receive
OHH services from a non-OTP OHH, the MOUD Prescriber must coordinate with the
OTP.
All MOUD prescribers must be involved in the services
described under Section 93.05-1. Activities may include, but are not limited
to, participating in team meetings, assisting with the coordination of care
across specialty and primary care providers, assessing risk of and discussing
with the member potential medication interactions, and providing assistance and
guidance in ensuring physical and behavioral health issues are addressed
through screening, care coordination, and health promotion.
3.
Nurse Care Manager - The
Nurse Care Manager must be either:
a. A
registered nurse, psychiatric nurse licensed as a registered professional nurse
and certified by the American Nurses Credentialing Center (ANCC) as a
psychiatric and mental health nurse (PMHN), APRN (as defined by the Maine State
Board of Nursing), or a Licensed Practical Nurse (LPN) who completes the SAMHSA
required training for an X-DEA license (i.e. SAMHSA approved eight-hour
training for Buprenorphine prescribing by physicians) within six (6) months of
initiating service delivery for OHH members. These providers may not continue
functioning as a Nurse Care Manager for more than six (6) months without
completing the appropriate training; or
b. An APRN who holds their X-DEA license.
The Nurse Care Manager shall contribute to
implementation, coordination, and oversight of each OHH member's Plan of
Care/ITP, assist in the coordination of care with outside providers, and
communicate barriers to adherence as appropriate to the team, including the
Clinical Team Lead.
The Nurse Care Manager position may be filled by another
appropriate licensed medical professional on the OHH team, as long as the
individual also meets the qualifications described
above.
4.
Clinical Counselor who supports individuals with (OUD) - The
Clinical Counselor must be:
a. A clinical
professional with a minimum certification as a Certified Alcohol and Drug
Counselor (CADC) or LADC; or
b. A
LCSW, Licensed Master Social Worker - Conditional Clinical (LMSW-CC), LCPC,
Licensed Clinical Professional Counselor - Conditional (LCPC-C), or Licensed
Marriage and Family Therapist (LMFT) or Licensed Marriage and Family Therapist
- Conditional (LMFT-C):
i. Who has completed a
minimum of sixty (60) hours of alcohol and drug education within the last five
(5) years; or
ii. Who, within a
maximum of five (5) years of initiating service delivery for OHH services, has
completed sixty (60) hours of alcohol and drug education.
The Clinical Counselor training must be documented and
records must be kept on file for review by the Department upon request.
The Clinical Counselor provides counseling related to
opioid dependency and individual or group substance use disorder outpatient
therapy for members receiving counseling. For all members, the Clinical
Counselor provides behavioral health expertise and contributes to care
planning, assessment of individual care needs, and identification of and
connection to behavioral health services, as part of the services described in
93.05-1.
5.
Patient Navigator - The
Patient Navigator must:
a. Have at least one
(1) year of job experience in a health/social services or behavioral health
setting and hold an Associate's degree; or
b. Be a Mental Health Rehabilitation
Technician/Community (MHRT/C) with at least one (1) year of related work
experience; or
c. Have a Bachelor's
degree from an accredited four-year institution of higher learning;
or
d. Be a medical assistant;
or
f. Be a registered nurse; or
g. Be the Nurse Care Manager described in
93.02-1(E)(3); or
h. Be the Clinical
Counselor described in 93.02-1(E)(4); or
i. Be a Community Health Worker (CHW) who has
completed a training program with a curriculum approved by the Department, or
their designee, that includes both relevant CHW core competencies and training
specific to OUD treatment and recovery; or holds a Maine CHW certification or
registration (effective the date such a designation becomes active in the State
of Maine).
The Patient Navigator shall work with the member to
collaborate with other health care, mental health, social service, and
community providers to guide the member in accessing additional services and
supports that will help the member in their
recovery.
6.
Recovery Coach - The Recovery Coach must:
a. Be an individual in long-term recovery or
a recovery ally, and
b. Effective
upon rule adoption, complete the 30-hour Connecticut Community for Addiction
Recovery (CCAR) training, or other Department-approved Recovery Coach training,
within six (6) months of the rule adoption date or within six (6) months of
beginning to deliver OHH services, whichever is later.
Recovery Coaches who are themselves in long-term recovery
are encouraged and preferred, as their life experiences and recovery allow them
to provide recovery support in such a way that others can benefit from their
experiences.
F. The OHH must adhere to applicable
licensing standards regarding documentation of all OHH providers'
qualifications in their personnel files. Pursuant to applicable licensing
standards, the OHH must have a review process to ensure that employees
providing OHH services possess the minimum qualifications set forth
above.
G. If an OHH member has a
primary care provider, the OHH must establish a relationship with that primary
care provider, authorized and evidenced by a signed medical release.* Such a
release is not required when the member's primary care provider is also the
member's provider within the OHH.
*The Department shall seek and anticipates receiving
approval for this section from the Centers for Medicare and Medicaid Services
(CMS). Pending approval, covered services will be provided as described in this
policy.
H. The OHH shall
ensure that it has policies and procedures in place to ensure that the Clinical
Team Lead and other team members, as appropriate, can communicate any changes
in patient condition that may necessitate treatment change with the member's
treating clinicians. This includes the requirement for establishing policies
and procedures around coordination, including but not limited to, a signed
medical release with the entities listed in 93.08(C) when applicable.
I. The OHH shall have in place
processes, procedures, and member referral protocols with local inpatient
facilities, Emergency Departments (EDs), 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 OHH shall have systematic follow-up protocols
to assure timely access to follow-up care.
J. The OHH must participate in
Department-approved OHH technical assistance and educational opportunities. At
least one (1) member of the care team must engage in these opportunities.
K. The OHH shall refer members to
another OHH or appropriate provider when a member requires treatment or a level
of care that the OHH does not offer.*
*The Department shall seek and anticipates receiving
approval for this section from the CMS. Pending approval, covered services will
be provided as described in this policy.
93.02-2
Core Standards
The OHH must demonstrate how it will meet the following
Core Standards prior to approval to provide services. Within the first three
(3) months following the start of the OHH's participation, the OHH shall
participate in an on-site assessment initiated by the Department, or its
authorized agent, to establish a baseline in meeting the Core Standards and
identify the OHH's training and educational needs. For the remainder of the
first year of participation, the OHH must submit quarterly reports on sustained
implementation of the Core Standards. After the first year, the OHH may request
the Department's approval to submit the Core Standard progress report annually
instead of quarterly.
The Core Standards are:
A.
Demonstrated Leadership - The
Clinical Team Lead of the OHH implements and oversees the Core Standards.
The Clinical Team Lead shall work with other providers
and staff in the OHH to build a team-based approach to care, continually
examine processes and structures to improve care, and assist with the review of
data on the quality performance of the practice.
B.
Team-Based Approach to Care -
The OHH shall implement a team-based approach to care delivery that includes
expanding the roles of non-physician providers (e.g. APRNs, physician
assistants, nurses, medical assistants) and non-licensed staff (e.g. recovery
coaches) to improve clinical workflows.
The OHH utilizes non-physician and non-licensed staff to
improve access and efficiency of the practice team in specific ways, including
one or more of the following:
1.
Through clear identification of roles and responsibilities;
2. Integrating care management into clinical
practice;
3. Expanding patient
education; and
4. Providing
greater data support to enhance the quality and cost-effectiveness of their
clinical work.
C.
Population Risk Stratification and Management - The OHH shall
adopt processes to identify and stratify patients across their population who
are at risk for adverse outcomes or are missing critical preventive services
and/or other health screenings. The OHH shall also adopt procedures that direct
resources or care processes to reduce those risks.
"Adverse outcomes," for purposes of this provision, means
a negative clinical outcome and/or avoidable use of healthcare services such as
hospital admissions, ED visits, or non-evidence-based use of diagnostic testing
or procedures.
D.
Enhanced Access - The OHH shall enhance access to services for its
population of patients, including:
1. The OHH
shall have a system in place that allows members to have same-day access to an
OHH team member using a form of care that meets the members' needs - e.g.
open-availability for same day access to an OHH team member, telephonic
support, and/or secure messaging.
2. The OHH shall have processes in place to
monitor and ensure access to care.
E.
Practice Integrated Care
Management - The OHH shall have processes in place to identify the need
for and provide care management services.
Care management staff shall have clear roles and
responsibilities, be integrated into the practice team, and receive explicit
training to provide care management services.
Care management staff shall have processes for tracking
outcomes for patients receiving care management services.
F.
Behavioral Physical Health
Integration - Upon approval as an OHH, the OHH shall complete a baseline
assessment of its behavioral-physical health integration capacity. Using
results from this baseline assessment, the OHH shall implement one or more
specific improvements to integrate behavioral and physical health care.
G.
Inclusion of Patients and
Families - The OHH shall include members and family members as
documented and regular participants at leadership meetings. The OHH shall have
in place a member and family advisory process to identify patient-centered
needs and solutions for improving care in the practice.
1. The OHH shall have processes in place to
support members and families to participate in these leadership and/or advisory
activities.
2. The OHH shall have
systems to gather member input, and family input when beneficial, at least
annually (e.g. via mail survey, phone survey, point of care questionnaires,
focus groups, etc.).
3. The OHH
shall have processes in place to design and implement changes that address
organizational needs and gaps in care identified via member and family
input.
H.
Connection to Community Resources and Social Support Services -
The OHH shall have processes in place to identify local community resources and
social support services.
The OHH shall have processes in place to routinely refer
patients and families to local community resources and social support services,
including those that provide self-management support to assist members in
overcoming barriers to care and meeting health goals.
I.
Commitment to Reducing Waste,
Unnecessary Healthcare Spending, and Improving Cost-effective Use of Healthcare
Services - The OHH shall have processes in place to reduce wasteful
spending of healthcare resources and improve the cost-effective use of
healthcare services as evidenced by at least one initiative that targets waste
reduction, including one or more of the following:
1. Reducing avoidable hospitalizations;
2. Reducing avoidable ED visits;
or
3. Working with the team to
develop new processes and procedures that improve patient experience and
quality of care, while reducing unnecessary use of services.
J.
Integration of Health
Information Technology - The OHH shall use 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 must be used to support member care, including
one or more of the following:
1. The
documentation of need and monitoring clinical care;
2. Supporting implementation and use of
evidence-based practice guidelines;
3. Developing Plans of Care/ITPs and related
coordination; or
4. Determining
outcomes (e.g., clinical, functional, recovery, satisfaction, and cost
outcomes).
