10206 MY HEALTH GPS SERVICES

10206.1 Each My Health GPS provider shall provide the following services to eligible beneficiaries:

1. (a) Comprehensive Care Management, as described in § 10206.3;
2. (b) Care Coordination, as described in § 10206.4;
3. (c) Health Promotion, as described in § 10206.5;
4. (d) Comprehensive Transitional Care, as described in § 10206.6;
5. (e) Individual and Family Support Services, as described in § 10206.7; and
6. (f) Referral to community and social support services, as described in § 10206.8.

10206.2 All My Health GPS services shall be delivered in accordance with best practice protocols developed by the Nurse Care Manager or practitioner with comparable qualifications, as approved by DHCF, of the My Health GPS provider and documented in the My Health GPS provider's certified EHR.

10206.3 Comprehensive Care Management shall consist of the creation, documentation, execution and maintenance of a person-centered plan of care. Activities included in the delivery of Comprehensive Care Management services include, but are not limited to, the following:

1. (a) Conducting an in-person comprehensive biopsychosocial needs assessment to collect behavioral, primary, acute and long-term care information from all health and social service providers appropriate for a particular beneficiary, including providers specific to pediatric beneficiaries, to inform development of the person-centered plan of care;
2. (b) Developing a person-centered plan of care that reflects the beneficiary's unique cultural needs and is developed in a language or literacy level that the beneficiary can understand, which is documented and maintained in the My Health GPS provider's certified EHR system and includes the following components:
3. (1) A list of the beneficiary's chronic conditions;
4. (2) Issues identified during the comprehensive biopsychosocial needs assessment described in (a);

(3) Identification of the beneficiary's strengths and needs;

(4) Individualized goals that address the beneficiary's chronic conditions and the issues identified during the assessment;

(5) Identification of interventions needed to support the beneficiary in meeting the individualized goals; and

(6) A plan to review the beneficiary's progress toward the individualized goals at set intervals and to revise the person-centered plan of care as appropriate;

(c) Updating the person-centered plan of care in the My Health GPS provider's certified EHR system as follows:

(1) Every twelve (12) months if the beneficiary has had no significant change in health condition;

(2) Each time the beneficiary has a significant change in health condition; and

(3) Within fifteen (15) days of discharge each time the beneficiary has an unplanned inpatient stay; and

(d) Monitoring the beneficiary's health status and documenting the beneficiary's progress toward the goals contained in the person-centered plan of care, including amending the plan of care as needed.

10206.4 Care Coordination shall consist of implementation of the person-centered plan of care through appropriate linkages, referrals, and coordination with needed services and supports. Care Coordination services include, but are not limited to, the following:

(a) Scheduling appointments and providing telephonic appointment reminders;

(b) Assisting the beneficiary in navigating health and social services systems, including behavioral health and housing supports as needed;

(c) Providing community-based outreach and follow-up, including face-to-face contact with beneficiaries in settings in which they reside, which may include shelters, the streets or other locations for homeless beneficiaries;

(d) Providing outreach and follow-up through remote means to beneficiaries who do not require in-person contact;

(e) Ensuring that all regular screenings are conducted through coordination with primary care or other appropriate providers;

(f) Ensuring medication reconciliation has been completed;

(g) Assisting with transportation to routine and urgent care appointments;

(h) Assisting with transportation for health-related activities;

(i) Assisting with completion of requests for durable medical equipment;

(j) Obtaining health records and consultation reports from other providers;

(k) Participating in hospital and emergency department transitions of care;

(l) Coordinating with Fire and Emergency Medical Services and DHCF initiatives to promote appropriate utilization of emergency medical and transport services;

(m) Facilitating access to urgent care appointments and ensuring appropriate follow-up care;

(n) Ensuring that the beneficiary is connected to and maintains eligibility for any public benefits to which the beneficiary may be entitled, including Medicaid; and

(o) Providing support to children transitioning from a pediatric practice to an adult practice.

10206.5 Health Promotion shall consist of the provision of health education to the beneficiary, as well as family members or other caregivers when appropriate, that is specific to the beneficiary's chronic conditions and needs as identified in the person-centered plan of care. Health Promotion services include, but are not limited to, the following:

(a) Assisting the beneficiary in developing a self-management plan to promote health and wellness, including activities such as substance abuse prevention, smoking prevention or cessation, and nutrition counseling;

(b) Connecting the beneficiary with peer or recovery supports;

(c) Providing support to improve the beneficiary's social network;

(d) Educating the beneficiary about accessing care in appropriate settings, including appropriate utilization of the 911 system;

(e) Assessing the beneficiary's understanding of his or her health conditions and motivation to engage in self-management;

(f) Using coaching and evidence-based practices such as motivational interviewing to enhance the beneficiary's understanding of his or her health conditions and motivation to achieve health and social goals; and

(g) Ensuring that health promotion activities align with the beneficiary's stated health and social goals.

10206.6 Comprehensive Transitional Care shall consist of the planned coordination of transitions between healthcare providers and settings in order to reduce emergency department and inpatient admissions, readmissions and length of stay. Comprehensive Transitional Care services shall include the following:

(a) Conducting in-person outreach to the beneficiary prior to discharge or within twenty-four (24) hours after discharge to support transitions from inpatient to other care settings, including the following activities:

(1) Reviewing the discharge summary and instructions;

(2) Ensuring that medication reconciliation has been completed;

(3) Ensuring that follow-up appointments and tests are scheduled and coordinated;

(4) Assessing the patient's risk status for readmission or other failure to obtain appropriate community-based care;

(5) Arranging for follow-up care, if indicated in the discharge plan;

(6) Planning for appropriate clinical care post-discharge, including home health services or other necessary skilled care;

(7) Planning for appropriate housing support services post-discharge, including facilitating linkages to temporary or permanent housing

(8) Arranging transportation for transitional care and follow-up appointments as needed; and

(9) Scheduling appointments for the beneficiary with a primary care provider or appropriate specialist(s) within one (1) week of discharge.

10206.7 Individual and Family Support Services shall consist of activities that assist the beneficiary and his or her support network (including family members and authorized representatives) in identifying and meeting the beneficiary's biopsychosocial needs and accessing necessary resources as identified in the person-centered plan of care. Individual and Family Support Services include, but are not limited to, the following:

1. (a) Facilitating beneficiary access to the following resources:
2. (1) Medical transportation services;
3. (2) Language interpretation services;
4. (3) Housing assistance services; and
5. (4) Any other social services needed by the beneficiary;
6. (b) Educating the beneficiary in self-management of his or her chronic conditions;
7. (c) Providing opportunities for family members and authorized representatives to participate in assessment activities and development of the person-centered plan of care;
8. (d) Ensuring that all My Health GPS services are delivered in a manner that is culturally and linguistically appropriate;
9. (e) Assisting the beneficiary in establishing and maintaining a network of natural supports;
10. (f) Promoting the beneficiary's personal independence;
11. (g) Including the beneficiary's family members and authorized representatives in quality improvement processes, including administering surveys to capture their experience with all My Health GPS services;
12. (h) Providing beneficiaries with access to their EHR or other clinical information, and providing access to their family members and authorized representatives if the beneficiary provides written authorization to do so; and

(i) Developing family support materials and services, including creating family support groups where appropriate.

10206.8 Referral to community and social support services shall consist of the process of connecting beneficiaries to resources to help them overcome access or service barriers, increase self-management skills, and achieve overall health, as identified in the person-centered plan of care, and ensuring that the referral is completed. Referrals to community and social support services may include but are not limited to:

1. (a) Wellness programs, including but not limited to smoking cessation, fitness, and weight loss programs;
2. (b) Support groups specific to the beneficiary's chronic condition(s);
3. (c) Substance abuse treatment services, including support groups, recovery coaches, and twelve (12)-step programs;
4. (d) Housing resources, including tenancy sustaining services;
5. (e) Social integration services, including psychiatric rehabilitation and peer support or consumer-run programs to foster recovery and community re-integration;
6. (f) Financial assistance, such as Temporary Assistance for Needy Families or Social Security;
7. (g) Supplemental Nutrition Assistance Program;
8. (h) Employment and educational programs or training;
9. (i) Legal assistance resources;
10. (k) Faith-based organizations; and
11. (l) Child care.

10206.9 Each My Health GPS entity shall ensure that enrolled beneficiaries do not receive services that duplicate My Health GPS services, as described in this chapter, through any other Medicaid-funded program.

SOURCE: Final Rulemaking published at 65 DCR 0636 (January 26, 2018); as amended by Final Rulemaking published at 66 DCR 5381 (April 26, 2019).