1. Health Homes: Lessons Learned (So Far) From a Phase II Health Home
Darcie Miller, DCS Orange County

2. “Hard work spotlights the character of people: some turn up their sleeves, some turn up their noses, and some don't turn up at all. “
Sam Ewing (born 1949)

3. Directors of Community Services
As the Chief Executive Officer of their Local Governmental Units (LGU’s), Directors of Community Services (DCSs) have a statutory responsibility and a prominent role in oversight of the mental hygiene system in New York, comprised of the Office of Mental Health, the Office of Alcoholism and Substance Abuse Services and the Office for People with Developmental Disabilities. In addition, the LGUs have a legal responsibility for ensuring the local, state and federal dollars supporting the system are being used for appropriate, quality services and that limited state and local resources are being maximized to meet the needs of all residents with mental illness and substance use disorders, not only those individuals who are insured through Medicaid (see MHL (8)).
CLMHD KH Jan 2013

4. CRITICAL PARTNERSHIPS: LDSS and LGU’s
Local District Social Services offices (LDSS) and local government units (LGUs) can be a valuable source of information to help outreach to and manage care for assigned members and a referral source for new members.
HH can exchange data with an LDSS or LGU by completing a DEAA subcontractor packet. The LDSS or LGU should determine which staff members need to access HH data (in addition to Medicaid staff who are automatically permitted access ) These staff members should be listed on the DEAA, and access to HH member data would be approved only for these individuals.
DOH October 2012 4

5. HEALTH HOME REFERRALS-INTERIM GUIDANCE
STEP 1- ASSESS ELIGIBLITY: Must meet eligibility for Health Home Services as described in the New York State Health Home State Plan Amendment (claims data should be used whenever available to verify medical and psychiatric diagnoses)
Two chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI over 25, or other chronic conditions, OR
One qualifying chronic condition (HIV/AIDS) and the risk of developing another, OR
One serious mental illness
DOH Oct 2012 5

6. HEALTH HOME REFERRALS-INTERIM GUIDANCE
STEP 2-ASSESS APPROPRIATENESS FOR HEALTH HOME: Has significant behavioral, medical or social risk factors which can be modified/ameliorated through care management including any of the following:
Probable clinical risk for adverse event, e.g., death, disability, inpatient or nursing home admission
Lack of or inadequate connectivity with healthcare system
Lack of or inadequate social/family/housing support
Non-adherence to treatments or medication(s) or difficulty managing medications
Recent release from incarceration or psychiatric hospitalization
Deficits in activities of daily living such as dressing, eating, etc
Learning or cognition issues
DOH Oct 2012 6

7. DOH October 2012 7

8. Payment Comparisons – Pairs Chronic and Triple Chronic Populations
DOH October 2012 8

9. Referral process for converting TCM programs may differ, e. g
Referral process for converting TCM programs may differ, e.g., OMH TCM programs and services must be made in consultation with the LGU Single Point of Access (SPOA). 9 9

10. LGU/SPOA process in a Health Home Environment

11. LGU/SPOA process in a Health Home Environment
The LGU/SPOA may make direct referrals for Health Home care management for individuals who meet the Health Home eligibility criteria. The following is the link to these criteria: pages 2 through 4. The “ground up” referral process for legacy capacity will take a different path than list-based referrals (referrals to Health Homes of eligible candidates provided by DOH for fee-for-service Medicaid participants and from Managed Care Organizations for Medicaid Managed Care participants) as follows:

12. LGU/SPOA process in a Health Home Environment
Fee-for-service Medicaid enrolled individuals may be referred directly to a Health Home care management program by a county. The process to implement this policy will be determined locally in partnership among the LGU/SPOA, Health Home, HHCM program and the MCO. Each locality should indicate what entities in their community may refer directly to a HHCM program (e.g., SPOA, inpatient units, treatment programs…). The care management program will add the individual to their tracking form that is submitted each month to the Health Home. An “R” will be entered on the tracking form to indicate that the person is newly referred (the date of service should be the first day of the month outreach and engagement to the individual began). For “legacy” TCM programs you will also enter a “Y” on the tracking form to indicate that you will be billing directly to EmedNY. Note this supersedes previous guidance to contact DOH to make the Health Home assignment.
For Medicaid Managed Care members the same process will be followed as in number one but the tracking form will be forwarded by the Health Home to the managed care company.
For people who: a) are on AOT status, b) have an enhanced service plan, c) are being discharged from an institute for mental disease (IMD) setting, or d) are being released from prison or jail (if over 30 days and the individual’s Medicaid status is on suspension but the individual remains Medicaid eligible) the LGU/SPOA will expect that all referrals from these settings will be accepted and the Health Home/MCO will ensure rapid (as defined by the LGU) access to the care management resource.

13. LGU/SPOA process in a Health Home Environment
Please be aware that in agreement with the Health Home, a former TCM program may expand capacity above the former legacy capacity. The LGU will need to be aware of where individuals are being referred for expansion capacity. This will assist the LGU and/or the SPOA to identify where capacity is available for referrals of individuals on assisted outpatient treatment status and who are returning to the community from non-Medicaid settings (e.g., prison, jail, state hospital). To assist this notification DOH is building a portal system (health commerce system) for the LGU to access.

14. LGU/SPOA process in a Health Home Environment
For individuals not enrolled in Medicaid, the LGU will continue to contract with the legacy TCM programs for State-funded care management services. These resources may only be expended on people with serious mental illness.
The LGU will also continue contracting for service dollars (100% State-funded) which may be expended on people with serious mental illness enrolled in both Medicaid and HHCM, as well as individuals described in the above paragraph.

15. LGU/SPOA process in a Health Home Environment
The LGU will also be involved in monitoring the quality of the HHCM program. It is expected that the LGU will have access to reports that DOH will be producing on a variety of quality indicators. All parties, OMH, DOH, LGU, MCO, HH and HHCM will need to partner in assuring that individuals participating in HHCM services are receiving the appropriate intensity of care as is indicated by their assessed need.

16. Health Home Guidance: Local Government Unit/ Single Point of Access
Prior OMH guidance on this topic is superseded by this new guidance below, effective January 28, 2013.
The LGU will continue to contract with the Health Home Care Management (HHCM) programs (former OMH Targeted Case Management (TCM)) and it is expected that Health Homes will also contract with these same programs.
The Health Home will look to care management as a tool that can assist with the development of an integrated plan of care and for utilization management of the members of the Health Home. The LGU/SPOA will look to the legacy capacity[1] from TCM as it is converted into HHCM and will require rapid access for individuals on assisted outpatient treatment status and those who are returning to the community from non-Medicaid settings (e.g., prison, jail, state hospital).
In order for rapid access (as described above) to occur, the HHCM program will need to manage its capacity and prioritize assignment of the referrals. The process to implement this policy will be determined locally in partnership among the LGU/SPOA, Health Home, HHCM program and the Managed Care Organization (MCO).
OMH has provided guidance specific to the assisted outpatient treatment (AOT) program and individuals who have volunteered to participate in enhanced service plans. This guidance is located at:
[1] Legacy capacity is the total number of slots funded in the former TCM program.

17. Medicaid Redesign Team Supported Housing
NYC RFP Criteria: Agencies must collaborate with at least one of the Health Homes established for the region where housing will be developed. If Health Homes are not yet established in the region where housing will be developed, agencies must agree to become a network member of the Health Home upon its establishment. Housing will be developed to target the appropriate housing for the population, i.e., provide in-reach, develop coordinated discharge/admission plans with Health Homes and identify/provide services and supports to ensure successful transition into the community. It is critical that agencies establish partnerships and/or collaborative agreements with at least one of the Health Homes serving the region. A list of designated Health Homes is available on the NYS Department of Health’s website at:

18. Medicaid Redesign Team Supported Housing

19. Medicaid Redesign Team Supported Housing

20. “What we hope ever to do with ease, we must learn first to do with diligence.“
Dr. Samuel Johnson ( )