Missouri Code of State Regulations
Title 9 - DEPARTMENT OF MENTAL HEALTH
Division 10 - Director, Department of Mental Health
Chapter 7 - Core Rules for Psychiatric and Substance Use Disorder Treatment Programs
Section 9 CSR 10-7.035 - Behavioral Health Healthcare Home
Universal Citation: 9 MO Code of State Regs 10-7.035
Current through Register Vol. 49, No. 6, March 15, 2024
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.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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