PURPOSE: This rule establishes the MO HealthNet Primary Care Health Home program for MO HealthNet participants with chronic conditions.

1. (1) Definitions.

   1. (A) EMR—Electronic Medical Records, also referred to as Electronic Health Records (EHR).
   2. (B) Health Home—A primary care practice 13 CSR 70-3

or site that provides comprehensive primary physical and behavioral health care to MHD patients with chronic physical and/or behavioral health conditions, using a partnership or team approach between the Health Home practice’s/site’s health care staff and patients in order to achieve improved primary care and to avoid preventable hospitalization or emergency department use for conditions treatable by the Health Home.

1. (C) Learning Collaborative—Group training sessions that primary care providers must attend if they are chosen to participate in the MO HealthNet Health Home program. The training will include meetings with mandatory attendance by certain officers and medical staff of the Health Home site and monthly conference calls.
2. (D) Meaningful Use Stage One—The American Recovery and Reinvestment Act (ARRA) of 2009 created the Electronic Health Records (EHR) incentive payments program to provide Medicare or Medicaid incentive payments to eligible professionals in primary care practices. Meaningful use means that the eligible professionals or providers document that they are using certified EHR technology in ways that can be measured significantly in quality and in quantity. Stage one of meaningful use means the eligible professionals meet twenty (20) out of twenty-five (25) meaningful use objectives as specified by the Centers for Medicare and Medicaid Services (CMS).
3. (E) MHD—MO HealthNet Division, Department of Social Services.
4. (F) NCQA—National Committee of Quality Assurance, the entity chosen by MHD to certify that a primary care practice has obtained a level of Health Home recognition after the practice achieves specified Health Home standards.
5. (G) Needy Individuals—Patients whose primary care services are either reimbursed by MHD or the Children’s Health Insurance Program (CHIP), or are provided as uncompensated care by the primary care practice, or are furnished at no cost or at reduced cost to patients without insurance.
6. (H) Patient Panel—The list of patients for whom each provider at the practice site serves as the primary care provider.
7. (I) CMS—Centers for Medicare and Medicaid Services.

1. (2) A primary care practice site shall meet the following requirements at the time of the site’s application to be considered for selection as a Health Home site by MHD and for participation in a Health Home learning collaborative:

   1. (A) It must have substantial Medicaid utilization in its patient population, with needy individuals comprising no less than twentyfive percent (25%) of its patient population;
   2. (B) It must demonstrate that it has strong engaged leadership committed to, and capable of, leading the practice site through a continuing Health Home transformation process and sustaining transformed practice processes;
   3. (C) It must have patient panels assigned to each primary care clinician;
   4. (D) It must actively utilize MHD’s comprehensive electronic health record for care coordination and prescription monitoring for MHD participants;
   5. (E) It must utilize an interoperable patient registry to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and produce exception reports for care planning;
   6. (F) It must meet the minimum access requirements of third-next-available appointment within thirty (30) days and same-day urgent care;
   7. (G) It must have completed EMR implementation and have been using EMR at stage one of meaningful use for at least six (6) months prior to the beginning of Health Home services; and
   8. (H) It must comply with established time frames for Health Home applications, inquiry submission, learning collaborative attendance, and any reporting deadlines.

2. (3) Health Home Responsibilities After Selection.

   1. (A) Health Home practice sites will be physicianor nurse practitioner-led and shall form a health team comprised of, at a minimum, a primary care physician (i.e., family practice, internal medicine, or pediatrics) or nurse practitioner, a licensed nurse or medical assistant, a behavioral health consultant, a nurse clinical care manager, and the practice administrator or office manager. The team will be supported as needed by the care coordinator and Health Home Director. Other team members may include, for example, dietitians, nutritionists, pharmacists, or social workers.

   2. (B) Practice sites selected to be MHD Health Homes shall participate in Health Home learning collaboratives. MHD will announce the dates and locations for learning collaborative meetings.

      1. 1. At a minimum, each Health Home

practice site shall send to the learning collaborative meetings a team consisting of a senior clinician, another clinician, and a non-clinician member of the practice (site) such as the practice manager or practice administrator.

1. 2. A Health Home will participate in

monthly learning collaborative conference calls or webinars.

1. 3. A Health Home will participate in

topical work groups as requested by MHD.

1. 4. A practice organization that has more

than one (1) of its practice sites recognized by MHD as Health Homes, but not all of its sites selected for learning collaborative participation, shall designate a trainer to participate in a “train the trainer” program. The trainer shall attend the learning collaborative as a member of a practice’s core practice team and then train all of the organization’s other Health Home practice sites that were not selected for learning collaborative participation. MHD or its designee shall identify content that the practice organization trainer will teach to the Health Home practice sites that do not participate in the learning collaborative.

1. (C) Health Homes shall convene practice team meetings at regular intervals to assist with the practice’s transformation into a Health Home and to support continual Health Home evolution.

2. (D) A Health Home shall create and maintain a patient registry using EHR software, a stand-alone registry, or a third-party data repository and measures reporting system. The patient registry is the system used to obtain information critical to the management of the health of a primary care practice’s patient population, including dates of services, types of services, and laboratory values needed to track chronic conditions. The Health Home’s patient registry will be used for—

   1. 1. Patient tracking;
   2. 2. Patient risk stratification;
   3. 3. Analysis of patient population health

status and individual patient needs; and

1. 4. Reporting as specified by MHD.

2. (E) Primary care practice sites must transform how they operate in order to become Health Homes. Transformation involves mastery of thirteen (13) Health Home core competencies to be taught through the learning collaborative. The thirteen (13) core competencies are—

   1. 1. Patient/family/peer/advocate/caregiv

er-centeredness or a whole-patient orientation to care;

1. 2. Multi-disciplinary team-based ap-

proach to care;

1. 3. Personal patient/primary care clini-

cian relationships;

1. 4. Planned visits and follow-up care;
2. 5. Population-based tracking and analy-

sis with patient-specific reminders;

1. 6. Care coordination across settings,

including referral and transition management;

1. 7. Integrated clinical care management

services focused on high-risk patients including medication management, such as medication histories, medication care plans, and medication reconciliation;

1. 8. Patient and family education;
2. 9. Self-management support by mem-

bers of the practice team;

1. 10. Involvement of the patient in goal

setting, action planning, problem solving, and follow-up;

1. 11. Evidence-based care delivery,

including stepped care protocols;

1. 12. Integration of quality improvement

strategies and techniques; and

1. 13. Enhanced access.

2. (F) By the eighteenth month following the receipt of the first MHD Health Home payment, a practice site participating in the Health Home program shall demonstrate to MHD that the practice site has either—

   1. 1. Submitted to the National Committee

of Quality Assurance (NCQA) an application for Health Home status and has obtained NCQA recognition of Health Home status at “Level 1 Plus.” “Level 1 Plus” recognition is defined for these purposes as meeting 2011 NCQA Level 1 standards, plus recognition for achieving the following 2011 NCQA patient-centered medical home standard at the specified level of performance: Standard 3C at one hundred percent (100%), or at seventy-five percent (75%) with an acceptable plan of correction; or

1. 2. Submitted to NCQA an application

for Health Home status and has obtained NCQA recognition of Health Home status at “Level 1 Plus,” defined as meeting NCQA 2008 PPC-PCMH Level 1 standards, plus recognition for achieving the following NCQA 2008 PPC-PCMH standards at the specified levels of performance: Standard 3C at seventy-five percent (75%), Standard 3D at one hundred percent (100%), and Standard 4B at fifty percent (50%).

1. (G) A Health Home shall submit to MHD or its designee the following information, as further specified by MHD or its designee, within the specified time frames:

   1. 1. Monthly narrative practice reports

that describe the Health Home’s efforts and progress toward implementing Health Home practices;

1. 2. Monthly clinical quality indicator

reports utilizing clinical data obtained from the Health Home’s patient registry or thirdparty data repository;

1. 3. Periodic submission of Medicaid

Home Implementation Quotient (MHIQ) survey scores, as specified by MHD; and

1. 4. Other reports as specified by MHD.
2. (H) Practices selected to participate in the and Procedure of General Applicability

Health Home program must provide evidence of Health Home practice transformation on an ongoing basis using measures and standards established by MHD. Evidence of Health Home transformation includes:

1. 1. Development of fundamental Health

Home functionality at six (6) months and at twelve (12) months of entering the Health Home program, based on an assessment process to be applied by MHD or its designee;

1. 2. Significant improvement on clinical

indicators specified by and reported to MHD or its designee; and

1. 3. Development of quality improvement

plans to address gaps and opportunities for improvement identified during and after the Health Home application process.

1. (I) A Health Home must notify MHD within five (5) working days of the following changes:

   1. 1. If the employment or contract of a

clinical care manager is terminated after the initiation of clinical care management payments;

1. 2. If the Health Home experiences sub-

stantive changes in practice ownership or composition, including:

1. A. Acquisition by another practice;
2. B. Acquisition of another practice; or
3. C. Merger with another practice.
4. (J) Health Homes shall participate in evaluations determined necessary by CMS and/or MHD. Participation in evaluations may require responding to surveys and requests for interviews of Health Home practice staff and patients. Health Homes shall provide all requested information to an evaluator in a timely fashion.

5. (K) Within three (3) months of selection to be a Health Home, a practice site will develop agreements or memorandums of understanding to formalize traditional care planning with area hospitals, in which the hospitals agree to—

   1. 1. Notify the Health Home when Health

Home patients are admitted to inpatient hospital departments;

1. 2. Identify for the Health Home individ-

uals seeking emergency department services who might benefit from connection with the Health Home;

1. 3. Notify the Health Home when Health

Home patients seek treatment in the hospitals’ emergency departments; and

1. 4. Refer patients to the Health Home for

follow-up care.

1. (4) Health Home Patient Requirements.

   1. (A) To become a MO HealthNet Health Home patient, an individual—

      1. 1. Must be an MHD participant or a

participant enrolled in an MHD managed care health plan; and

1. 2. Must have at least—

   1. A. Two (2) of the following chronic

health conditions:

1. (I) Asthma;
2. (II) Diabetes;
3. (III) Cardiovascular disease;
4. (IV) A developmental disability; or
5. (V) Be overweight, as evidenced by

having a body mass index (BMI) over twenty-five (25); or

1. B. One (1) chronic health condition

and be at risk for a second chronic health condition as defined by MHD. In addition to being a chronic health condition, diabetes shall be a condition that places a patient at risk for a second chronic condition. Smoking or regular tobacco use shall be considered atrisk behavior leading to a second chronic health condition.

1. (B) A participant eligible for Health Home services and identified by MHD as an existing user of Health Home services will be auto-assigned to a Health Home based on qualifying chronic health conditions. A participant not enrolled in an MHD managed care health plan will be attributed to a Health Home using a standard patient algorithm adopted by MHD. A participant enrolled in an MHD managed care health plan will be attributed to a Health Home practice site that the participant has selected or to which the participant has been assigned by the health plan.

2. (C) After being assigned to Health Homes, participants will be granted the option at any time to change their Health Homes if desired. A participant assigned to a Health Home will be notified by MHD of all available Health Home sites throughout the state. The notice will—

   1. 1. Describe the participant’s choice in

selecting a Health Home;

1. 2. Provide a brief description of Health

Home services, including the role of care managers and coordinators; and

1. 3. Describe the process for the partici-

pant to opt out of receiving services from the assigned Health Home provider.

1. (D) Participants eligible for Health Home services who receive inpatient hospital or hospital emergency department services will be notified of eligible Health Homes and will be referred to Health Homes based on their choice of providers. Participants who are admitted to a hospital or who receive hospital emergency department services will be identified as eligible for Health Home services through the MHD comprehensive Medicaid electronic health record.
2. (E) Health Home providers to which patients have been auto-assigned will be noti- 13 CSR 70-3

fied by MHD of patients’ enrollment for Health Home services. The Health Homes will notify their patients’ other treatment providers in order to explain Health Home goals and services, and to encourage their patients’ other treatment providers to participate in care coordination efforts.

1. (5) Required Health Home Services.

   1. (A) All Health Homes shall provide clinical care management services for enrolled patients, including those who are at high risk for future hospital inpatient admissions or hospital emergency department use.

      1. 1. Essential clinical care management

services include:

1. A. Identification of high-risk patients

and use of patient information to determine the level of participation in clinical care management services;

1. B. Assessment of preliminary service

needs;

1. C. Individual treatment plan develop-

ment for each patient, including patient goals, preferences, and optimal clinical outcomes;

1. D. Intensive monitoring, follow-up,

and clinical management of high-risk patients;

1. E. Assignment of health team roles

and responsibilities by the clinical care manager;

1. F. Monitoring of individual and popu-

lation health status and service use to determine adherence to, or variance from, treatment guidelines;

1. G. Development of treatment guide-

lines for health teams to follow across risk levels or health conditions; and

1. H. Development and dissemination of

reports that indicate progress toward meeting desired outcomes for client satisfaction, health status, service delivery, and costs.

1. 2. Clinical care management activities

generally include frequent patient contact, clinical assessment, medication review and reconciliation, communication with treating clinicians, and medication adjustment by protocol.

1. 3. A Health Home shall employ or con-

tract with at least one (1) licensed nurse as the Health Home clinical care manager responsible for providing clinical care management services. The clinical care manager shall function as a member of the Health Home practice team whenever patients of the practice team are receiving clinical care management services.

1. 4. Health Homes shall ensure and docu-

ment that funding for clinical care management services is used exclusively to provide clinical care management services.

1. 5. Recognized Health Homes may col-

laborate in the provision of clinical care management services.

1. (B) Health Homes shall provide health promotion services for their patients. Health promotion services include:

   1. 1. Providing health education specific to

a patient’s chronic conditions;

1. 2. Emphasizing patient self-direction,

planning, and skill development so patients can help manage and monitor their chronic health conditions;

1. 3. Providing support for improving

social networks; and

1. 4. Providing health-promoting lifestyle

interventions, including but not limited to:

1. A. Substance abuse prevention;
2. B. Smoking prevention and cessation;
3. C. Nutritional counseling;
4. D. Obesity prevention and reduction;

and

1. E. Physical exercise activities.

2. (C) All Health Homes shall provide comprehensive care coordination services necessary to implement individual treatment plans, reduce hospital inpatient admissions, and interrupt patterns of frequent hospital emergency department use.

   1. 1. Care coordination requires that a

member of the Health Home team assist patients in the development, revision, and implementation of their individual treatment plans.

1. 2. Care coordination also includes

appropriate linkages, referrals, and followups to needed services and supports.

1. 3. Health Homes that specialize in pri-

mary physical health care shall obtain the services of a licensed behavioral health professional to assist with care coordination services.

1. 4. Other essential care coordination

activities include:

1. A. Appointment scheduling;
2. B. Arranging transportation for medi-

cally-necessary services;

1. C. Monitoring referrals and follow-

ups;

1. D. Providing comprehensive transi-

tional care by collaborating with physicians, nurses, social workers, discharge planners, pharmacists, and other health care professionals to continue implementation of patients’ treatment plans;

1. E. For patients with developmental

disabilities (DD), coordinating with DD case managers for services more directly related to habilitation and other DD-related services;

1. F. Referring Health Home patients to

social and community resources for assistance in areas such as legal services, housing, and disability benefits; and

1. G. Providing individual and family

support services by working with patients and their families to increase their abilities to manage the patients’ care and live safely in the community.

1. (6) Hospitals and participating Health Home sites shall communicate transitional care planning for Health Home participants, including inpatient discharge planning, such that effective patient-centered, quality-driven provider coordination is ensured.

2. (7) Health Home Payment Components.

   1. (A) General.

      1. 1. All Health Home payments to a prac-

tice site are contingent on the site meeting the Health Home requirements set forth in this rule. Failure to meet these requirements is grounds for revocation of a site’s Health Home status and termination of payments specified within this rule.

1. 2. MO HealthNet Health Home reim-

bursement will be in addition to a provider’s existing MHD reimbursement for services and procedures and will not change existing reimbursement for a provider’s non-Health Home services and procedures.

1. 3. No Health Home payments will be

made to an MHD Health Home until the calendar month immediately following the Health Home’s first learning collaborative session.

1. 4. Should experience reveal to MHD

that elements of the Health Home payment methodology will not function, or are not functioning, as MHD intended, MHD reserves the right to make changes to the payment methodology after consultation with recognized Health Homes and receipt of required federal approvals.

1. (B) MHD Health Homes shall receive permember-per-month (PMPM) payments to reimburse Health Home sites for costs incurred for patient clinical care management services, comprehensive care coordination services, health promotion services, and Health Home administrative and reporting costs.

   1. 1. A Health Home’s PMPM reimburse-

ment will be determined from the number of patients that choose, or are assigned to, the Health Home site.

1. 2. A current month’s PMPM payments

to a Health Home site will be based on—

1. A. The number of Health Home-eligi-

ble patients receiving Health Home services at the Health Home in the month considered for payment;

1. B. The number of Health Home-eligi-

ble patients in subparagraph (7)(B)2.A. who are assigned to the Health Home at the beginning of the month considered for payment; and

1. C. The number of Health Home-eligi-

ble patients in subparagraphs (7)(B)2.A. and (7)(B)2.B. who are Medicaid-eligible at the end of the month considered for payment.

1. 3. During the first year of participation

in the Health Home program, a Health Home will receive PMPM payments only for MHD or MHD managed care participants—

1. A. With two (2) or more of the fol-

lowing chronic conditions:

1. (I) Asthma;
2. (II) Diabetes;
3. (III) Cardiovascular disease,

including hypertension;

1. (IV) Overweight (BMI > 25); or
2. (V) Developmental disabilities; or
3. B. With one (1) of the conditions in

subparagraph (7)(C)3.A. and be at risk for a second chronic condition because of diabetes or tobacco use.

1. 4. In order to generate a PMPM pay-

ment to a Health Home, a patient assigned to the Health Home must have received at least one (1) non-Health Home service based on paid Medicaid fee for service or managed care claims.

1. 5. In order to receive PMPM payments,

a Health Home must demonstrate to MHD that the Health Home has hired, or has contracted with, a clinical care manager to provide services at the Health Home site.

1. (8) Health Home Corrective Action Plans.

   1. (A) Health Homes shall undergo an assessment process to be applied by MHD or its designee at six (6) months and at twelve (12) months of entering the Primary Care Health Home program. If the assessment shows that a Health Home practice site fails to meet the Health Home requirements as set forth in section (3) of this rule, or fails to provide the required Health Home services as set forth in section (5) of this rule, the Health Home practice site shall participate in a corrective action plan to address any such failures disclosed as a result of the assessment process. The corrective action plan will last for six (6) months and may be extended or renewed at MHD’s discretion. At the end of the corrective action plan period, the Health Home practice site will be reassessed to determine its compliance with the requirements of this rule.
   2. (B) The Health Home practice site will be reassessed at the end of the corrective action plan period, including any extensions and renewals granted by MHD. If the reassessment shows that the Health Home still fails to meet Health Home requirements or provide required Health Home services, MHD shall and Procedure of General Applicability 13 CSR 70-3

terminate the Health Home practice site from the Primary Care Health Home program.

AUTHORITY: section 208.201, RSMo Supp. 2011.* Original rule filed Dec. 15, 2011, effective July 30, 2012.

*Original authority: 208.201, RSMo 1987, amended 2007.