C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-91.07 - HOME COVERED SERVICES

The HOME Provider shall conduct outreach to underserved Members with high emergency services utilization, chronic conditions, complex care coordination needs, and Long-term Homelessness in need of intensive HOME services. The HOME services tier in which the Member is enrolled will determine the intensity level required for each service.

91.07-1Comprehensive Care Management

Comprehensive Care Management includes the following:

1. Within the first thirty (30) days following a Member's enrollment for HOME services, the HOME Provider shall conduct a face-to-face comprehensive assessment which shall include:

a. An individual housing assessment;

b. A SPDAT or Y-SPDAT assessment;

c. A psychosocial assessment, which shall include, at minimum, a history of trauma and abuse; housing instability; substance use; general health and capabilities; behavioral health and capabilities; and medication needs. The psychosocial assessment shall also identify Member strengths and how they can be optimized to promote:

i. Medical and behavioral health goals;

ii. Housing goals;

iii. Available support systems;

iv. Community integration;

v. Employment and/or educational status; and

vi. Self-management and self-advocacy.

The SPDAT or Y-SPDAT assessment shall be repeated every 90 days or more often when indicated by a significant change in the Member's circumstances or needs. Comprehensive reassessment must reoccur as changes in the Member's needs warrants or, at a minimum, on an annual basis.

2. Plan of Care: Based on the comprehensive assessment, within the first thirty (30) calendar days following a Member's enrollment, the HOME Provider in partnership with the Member, shall draft a comprehensive, individualized, and Member-driven Plan of Care that shall identify and integrate housing needs and goals. The HOME Provider shall be responsible for the management, oversight, and implementation of the Plan of Care, including ensuring active Member participation and that measurable progress is made on these goals.

a. The Member or the Member's parent or legal guardian, as appropriate, shall consent to the Plan of Care which shall be:

i. Reflected by the appropriate signature on the Plan of Care; and

ii. Documented in the Member's record; and

iii. Accessible to the Member, the Member's legal guardian, the HOME Provider, primary care provider, and other providers, as appropriate.

b. The HOME Provider shall obtain written consent for services and authorization for the release and sharing of information from each Member or the Member's parent or legal guardian, as appropriate;

c. If authorized by the Member or the Member's parent or legal guardian, as appropriate, the HOME Provider shall document in the Plan of Care the Member's preferred family supports, or other support systems and preferences. If authorized by the Member or the Member's parent or legal guardian, as appropriate, the Plan of Care shall be accessible to the Member's family, guardian(s), or other caregivers;

d. The Plan of Care shall address, but not be limited to, the areas of housing, prevention, wellness, harm reduction, peer supports, health promotion and education, crisis planning, and identifying other social, residential, educational, vocational, and community services and supports that enable a Member to achieve physical, social, and behavioral health goals;

e. The Plan of Care shall include the development of an individualized housing support plan based upon the comprehensive assessment that addresses identified barriers, including short and long-term measurable goals for each need, establishes the Member's approach to meeting the goals, and identifies when community supports and services may be required to meet the goals;

f. As part of the Plan of Care, the HOME Provider shall develop with the Member a crisis management plan based upon the comprehensive assessment to develop crisis prevention and early resolution strategies.

The Member plays a central and active role in the development and maintenance of the crisis management plan, which shall clearly identify the known pre-cursors to crisis and the strategies and techniques to be utilized to stabilize each situation. The crisis management plan shall identify goals and interventions to produce effective crisis prevention, de-escalation, and resolution;

g. The Plan of Care shall identify Member strengths and how these strengths can be optimized to promote goals. The Member shall play a central and active role in the development and maintenance of the Plan of Care, which shall clearly identify the goals and timeframes for improving the Member's health and health care status, and the interventions that will produce this outcome;

h. The Plan of Care shall clearly identify providers involved in the Member's care, such as the primary care provider, specialist(s), behavioral health care provider(s), and other providers directly involved in the Member's care;

i. All identified clinical services indicated in the Plan of Care must be approved by a medical or behavioral health professional working within the scope of their license;

j. The Plan of Care must be reviewed and approved in writing by an appropriately licensed medical or mental health professional within the first thirty (30) calendar days following acceptance of the Plan by the Member or the Member's parent or legal guardian, as appropriate, and every ninety (90) calendar days thereafter or more frequently if indicated in the Plan of Care. The Clinical Leader with other care team members, as appropriate, shall review the Plan of Care as changes in the Member's needs occur, or at least every ninety (90) days, to determine the efficacy of the services and supports and formulate changes in the Plan as necessary with Member consultation;

k. The HOME Provider shall consult with care team members, the Member, and the Member's parent or legal guardian, as appropriate, when changes in the Member's situation or needs occur and update the Plan of Care accordingly to ensure that it remains current; and

l. The Member may decline services identified in the Plan of Care, the HOME Provider shall document the declination in the Member's record.

3. Integration with Primary Care. During the first three (3) months after a Member's enrollment, the HOME Provider shall provide ongoing individualized outreach, education, and support to the Member regarding HOME services and benefits, including information on sharing personal health information and coordination with primary care services.

4. The HOME Provider shall work with Members and appropriate providers to scan for gaps in the Member's care by reviewing Member feedback, referral completion records, or, at a minimum, Department provided utilization reports.

91.07-2Care Coordination

The HOME Provider shall provide care coordination to address the Members' complex needs and to overcome barriers to care by facilitating access to all medically necessary clinical and non-clinical health-related social needs. Care coordination includes but is not limited to the following:

1. Assistance in establishing a primary care provider and accessing health care and follow-up care;

2. Assessing housing needs and providing coordination and tenancy support services to help the Member access and maintain safe/affordable housing;

3. Assessing employment needs and providing assistance to access and maintain employment;

4. Conducting outreach to family members and others to support connections to services and expand social networks;

5. Assistance in locating and accessing community social, legal, medical, behavioral healthcare, and transportation services;

6. Ensuring that Members have access to crisis intervention and resolution services, coordinate follow up services to ensure that a crisis is resolved, and assist in the development and implementation of crisis management plans; and

7. Maintaining frequent communication with other team providers to monitor health status and to ensure that the Plan of Care is effectively implemented and adequately addresses the Member's needs.

91.07-3Health Promotion

Health Promotion is a set of services that emphasize self-management of physical and behavioral health conditions. The HOME Provider shall:

1. Provide education, information, training, and assistance to Members for the development of self-monitoring and management skills to support Members in attaining the goals of the Plan of Care;

2. Promote healthy lifestyle, psychosocial health, and wellness strategies including, but not limited to, substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention, harm reduction, conflict resolution, problem solving, risk avoidance, and increasing physical activities; and

3. Coordinate and provide access to self-help/self-management and advocacy groups and shall implement population-based strategies that engage Members with services necessary for both preventative and chronic care.

91.07-4Comprehensive Transitional Care

Comprehensive Transitional Care services are designed to ensure continuity and coordination of care, prevent the unnecessary use of the ED and hospitals, ensure safe and effective discharges or releases (including from incarceration), and/or prevent loss of housing and health gains acquired through HOME services. To provide Comprehensive Transitional Care, the HOME Provider shall:

1. Collaborate with shelter staff, facility discharge planners, incarceration officials, other community setting managers, the Member, the Member's parent or legal guardian when appropriate, and, with the Member's consent, the Member's family or other support system to ensure a coordinated, safe transition to housing in the community;

2. Provide Members with care coordination and support services, including, but not limited to, housing navigator services, peer support services, and psychosocial and care coordination supports to assist the Member attain and transition to housing;

3. Follow-up with Members following a hospitalization, use of crisis service, out-of-home placement, or incarceration;

4. Collaborate with Members, their families, and facilities to ensure a coordinated, safe transition between different sites of care or transfer from the home/community setting into a facility;

5. Assist the Member explore less restrictive alternatives to hospitalization/ institutionalization; and

6. Provide timely and appropriate follow-up communications on behalf of transitioning Members, which includes a clinical hand off, timely transmission, and receipt of the transition/discharge plan, review of the discharge records, and coordination of the transition to housing.

91.07-5Individual and Family Support Services

Individual and family support services include assistance and support to the Member and/or the Member's family in implementing the Plan of Care. The HOME Provider shall:

1. Provide assistance with housing and health-system navigation and training on self-advocacy skills;

2. Provide information, consultation, and problem-solving support services to the Member, and his or her family or other support system, in order to assist the Member in the use of self-management skills to reduce emergency service utilization and maintain housing;

3. Support and assist the Member to engage in employment, education, vocational, and housing opportunities to establishing housing-, health-, and independence-sustaining skills;

4. Assist the Member to develop communication skills necessary to obtain and maintain housing and employment and request assistance or clarification from landlords, neighbors, supervisors, and co-workers when needed;

5. Support the Member to implement his/her crisis management plan to prevent crises and implement early resolution strategies. The Member shall play a central and active role in the implementation of the crisis management plan to attain effective crisis prevention, de-escalation, and resolution;

6. Coordinate and provide access to peer support services, Peer advocacy groups, and other Peer-run or Peer-centered services and help the Member identify and develop natural support systems; and

7. Discuss advance directives with Members and their family, guardian(s), or caregivers, as appropriate.

91.07-6Referral to Community and Social Support Services

1. The HOME Provider shall provide referrals based on the assessment and Member's care plan as appropriate. Referrals will be made through telephone or in person and may include electronic transmission of requested data. The HOME Provider shall follow through on referrals to encourage the Member to connect with the services.

2. The HOME Provider shall provide referrals to community, social support, and recovery services. The HOME Provider shall connect Members to community and social service support organizations that offer supports for crisis intervention, management and resolution, self-management and healthy living, and basic social service needs such as transportation assistance, housing, literacy, employment, economic, and other assistance.

3. When able through the acquisition of appropriate releases, all referrals should be shared and documented in the Plan of Care through Care Coordination.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.07