PURPOSE: This rule prescribes a Health Home as an alternative approach to the delivery of health-care services that promises better experience and better results than traditional care. This rule also establishes the payment methodology for those Community Mental Health Centers (CMHCs) participating as a Health Home.

1. (1) Definitions.

   1. (A) Community Mental Health Centers (CMHC)—An agency and its approved designee(s) authorized by the Division of Comprehensive Psychiatric Services (CPS) as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the division.
   2. (B) Department—Missouri Department of Mental Health (DMH).
   3. (C) Electronic Medical Record (EMR) (also referred to as Electronic Health Records (EHR))—An electronic version of a patient’s medical history that is maintained by the provider over time and may include all of the key administrative clinical data relevant to that person’s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EMR automates access to information and has the potential to streamline the clinician’s workflow. The EMR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
   4. (D) Health Home (also referred to as Health Care Home)—A site that provides comprehensive behavioral health care coordinated with comprehensive primary physical care to Medicaid patients with behavioral health and/or chronic physical health condi- 9 CSR 10-5

tions, 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 hospitalization or emergency room use.

1. (E) Learning Collaborative—Group training sessions that CMHCs must attend if they are chosen to participate in the Missouri Medicaid Community Mental Health Center Health Home program.
2. (F) Missouri Medicaid Audit and Compliance Unit (MMAC)—The unit within the Department of Social Services (DSS) which directly manages and administers Medicaid provider review, program integrity, audit and compliance initiatives, and provider contracts of the Medicaid program.
3. (G) MO HealthNet Division (MHD)—The Missouri Medicaid agency.
4. (H) Needy individuals—Individuals receiving medical assistance from Medicaid or the Children’s Health Insurance Program (CHIP), or are furnished uncompensated care by the provider, or furnished services at either no cost or reduced cost based on a sliding scale.

1. (2) Health Home Qualifications.

   1. (A) Initial Provider Qualifications. In order to be recognized as a Health Home, a CMHC must, at a minimum, meet the following criteria:

      1. 1. Have a substantial percentage of its

patients enrolled in Medicaid, with special consideration given to those with a considerable volume of needy individuals;

1. 2. Have strong, engaged leadership per-

sonally committed to and capable of leading the practice through the transformation process and sustaining transformed practice processes as demonstrated through the application process and agreement to participate in learning activities; and that agency leadership have presented the state-approved “Paving the Way for Health Homes” PowerPoint introduction to Missouri’s Health Home Initiative to all agency staff;

1. 3. Meet the state’s minimum access

requirements. Prior to implementation of Health Home service coverage, provide assurance of enhanced patient access to the health team, 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;

1. 4. Actively use MHD’s comprehensive

EHR to conduct care coordination and prescription monitoring for Medicaid participants;

1. 5. Utilize an interoperable patient reg-

istry to input annual metabolic screening results, track and measure care of individuals, automate care reminders, and produce exception reports for care planning;

1. 6. Routinely use a behavioral pharmacy

management system to determine problematic prescribing patterns;

1. 7. Conduct wellness interventions as

indicated based on client’s level of risk;

1. 8. Complete status reports to document

client’s housing, legal, employment status, education, custody, etc.;

1. 9. Agree to convene regular, ongoing

and documented internal Health Home team meetings to plan and implement goals and objectives of practice transformation;

1. 10. Agree to participate in the Centers

for Medicare and Medicaid Services (CMS) and state-required evaluation activities;

1. 11. Agree to develop required reports

describing CMHC Health Home activities, efforts, and progress in implementing Health Home services;

1. 12. Maintain compliance with all of the

terms and conditions as a CMHC Health Home provider or face termination as a provider of CMHC Health Home services; and

1. 13. Present a proposed Health Home

delivery model that the state determines to have a reasonable likelihood of being cost effective. Cost effectiveness will be determined based on the size of the Health Home, Medicaid caseload, percentage of caseload with eligible chronic conditions of patients, and other factors to be determined by the state.

1. (B) Ongoing Provider Qualifications. Each CMHC must also—

   1. 1. Within three (3) months of Health

Home service implementation, have a contract or Memorandum of Understanding (MOU) under development with regional hospital(s) or system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions of Health Home participants, as well as maintain a mutual awareness and collaboration to identify individuals seeking emergency department (ED) services that might benefit from connection with a Health Home site, and in addition motivate hospital staff to notify the CMHC primary care nurse manager or staff of such opportunities;

1. 2. Develop quality improvement plans to

address gaps and opportunities for improvement identified during and after the application process;

1. 3. Demonstrate continuing development

of fundamental Health Home functionality at six (6) months and twelve (12) months through an assessment process to be determined by DMH;

1. 4. Demonstrate improvement on clinical

indicators specified by and reported to the state; and

1. 5. Meet accreditation standards approved

by the state as such standards are developed.

1. (3) Scope of Services. This section describes the activities CMHCs will be required to engage in and the responsibilities they will fulfill if recognized as a Health Home provider.

   1. (A) Health Home Services. The Health Home Team shall assure that the following health services are received as necessary by all members of the Health Home:

      1. 1. Comprehensive Care Management.

Comprehensive care management includes the following services:

1. A. Identification of high-risk individ-

uals and use of client information to determine level of participation in care management services;

1. B. Assessment of preliminary service

needs;

1. C. Development of treatment plans,

including client goals, preferences, and optimal clinical outcomes;

1. D. Assignment of Health Team roles

and responsibilities;

1. E. Development of treatment guide-

lines that establish clinical pathways for health teams to follow across risk levels or health conditions;

1. F. Monitoring of individual and popu-

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

1. G. Development and dissemination of

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

1. 2. Care coordination. Care coordination

consists of the implementation of the individualized treatment plan (with active client involvement) 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: appointment scheduling, conducting referrals and followup monitoring, participating in hospital discharge processes, and communicating with other providers and clients/family members. Health Homes must conduct care coordination activities across the Health Team. The primary responsibility of the Nurse Care Manager is to ensure implementation of the treatment plan for achievement of clinical outcomes consistent with the needs and preferences of the client.

1. 3. Health promotion services. Services

shall minimally consist of providing health education specific to an individual’s chronic conditions, development of self-management plans with the individual, education regarding the importance of immunizations and screening, child physical and emotional development, providing support for improving social networks, and providing health promoting lifestyle interventions, including, but not limited to: substance use prevention, smoking prevention and cessation, nutritional counseling, obesity reduction and prevention, and increasing physical activity. Health promotion services also assist clients to participate in the implementation of the treatment plan and place a strong emphasis on personcentered empowerment to understand and self-manage chronic health conditions.

1. 4. Comprehensive transitional care.

Members of the Health 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 Health 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 clients’ 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.

1. 5. Individual and family support ser-

vices. Services include, but are not limited to: advocating for individuals and families; assisting with, obtaining, and adhering to medications and other prescribed treatments. In addition, Health 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 increasing health literacy, ability to self-manage care, and facilitate participation in the ongoing revision of their care/treatment plan. For individuals with developmental disabilities (DD) the Health Team will refer to and coordinate with the approved DD case management entity for services more directly related to habilitation or a particular health care condition.

1. 6. Referral to community and social

support. Involves providing assistance for clients to obtain and maintain eligibility for health care, disability benefits, housing, personal need, and legal services, as examples. For individuals with DD, the Health Team will refer to and coordinate with the approved DD case management entity for this service.

1. (B) Health Home Staffing. Health Home providers will augment their current Community Psychiatric Rehabilitation (CPR) teams by adding a Health Home Director, Physician Leadership, and Nurse Care Managers to provide consultation as part of the Care Team and assist in delivering Health Home services. Clerical support staff will also be funded to assist with Health Home supporting functions.

2. (C) Learning Activities. CMHCs will be supported in transforming service delivery by participating in statewide learning activities. Given CMHCs’ varying levels of experience with practice transformation approaches, the state will assess providers to determine learning needs. CMHCs will therefore participate in a variety of learning supports, up to and including learning collaborative, specifically designed to instruct CMHCs to operate as Health Homes and provide care using a whole person approach that integrates behavioral health, primary care, and other needed services and supports.

   1. 1. Learning activities will support

providers of Health Home services in addressing the following components:

1. A. Provide quality-driven, cost-effec-

tive, culturally-appropriate, and person-andfamily-centered Health Home services;

1. B. Coordinate and provide access to

high-quality health care services informed by evidence-based clinical practice guidelines;

1. C. Coordinate and provide access to

preventive and health promotion services, including prevention of mental illness and substance use disorders;

1. D. Coordinate and provide access to

mental health and substance use services;

1. E. Coordinate and provide access to

comprehensive care management, care coordination, and transitional care across settings;

1. F. Coordinate and provide access to

chronic disease management, including selfmanagement support to individuals and their families;

1. G. Coordinate and provide access to

individual and family supports, including referral to community, social support, and recovery services;

1. H. Coordinate and provide access to

long-term care supports and services;

1. I. Develop a person-centered care

plan for each individual that coordinates and integrates all of his or her clinical and nonclinical health care related needs and services;

1. J. Demonstrate a capacity to use

health information technology to link services, facilitate communication among team members and between the Health Team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and

1. K. Establish a continuous quality

improvement program and collect and report 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.

1. (D) Patient Registry. Health Homes shall utilize the DMH/Department of Social Services (DSS) provided EHR patient registry. A patient registry is a system for tracking information that DMH/DSS deems critical to the management of the health of a Health Home’s patient population, 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. 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 DMH.

2. (E) Data Reporting. CMHCs shall submit to DMH the following reports, as further specified by DMH, within the time frames specified below:

   1. 1. Monthly update CMHC report that

describes the CMHC’s efforts and progress to implement Health Home; including identifying the CMHC leadership and Health Home staffing and providing updates on Health Home enrollment status; and

1. 2. Other reports, as specified by

DMH/DSS.

1. (F) Demonstrated Evidence of Health Home Transformation. CMHCs are required to demonstrate evidence of Health Home transformation on an ongoing basis using measures and standards established by DSS and DMH, and communicated to the CMHCs. Evidence of Health Home transformation includes:

   1. 1. Demonstrates development of funda-

mental health home functionality at six (6) months and twelve (12) months based on an assessment process to be determined by DMH; and

1. 2. Demonstrates improvement on clini-

cal indicators specified by and reported to DMH.

1. (G) Participation in Evaluation. CMHCs shall participate in an evaluation. Participation may entail responding to surveys and requests for interviews with CMHC staff and clients. CMHCs shall provide all 9 CSR 10-5

requested information to the evaluator in a timely fashion.

1. (H) Notification of Staffing Changes. Practices are required to notify DMH within five (5) working days of staff changes in Health Home Director, Physician Leadership, Nurse Care Managers, and Clerical Support Staff.
2. (I) CMHCs shall work cooperatively with DMH to support DMH approved training, technology, and administrative services required for implementation of the Health Care Home Program.

1. (4) Patient Eligibility and Enrollment.

   1. (A) Medicaid beneficiaries eligible for Health Home services from recognized CMHC Health Home service providers must meet one (1) of the following criteria:

      1. 1. Diagnosed with a serious and persis-

tent mental health condition (adults with Seriously Mentally Ill (SMI) and children with Serious Emotional Disturbance (SED)); or

1. 2. Diagnosed with a mental health con-

dition and substance use disorder; or

1. 3. Diagnosed with a mental health con-

dition and/or substance use disorder, and one (1) other chronic condition (diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular disease, overweight (body mass index (BMI) > 25), tobacco use, and developmental disability).

1. (B) Individuals eligible for Health Home services and identified by the state as being an existing service user of a Health Home will be auto-assigned to eligible providers based on qualifying conditions. Individuals will be attributed to the CMHC using a standard patient attribution algorithm adopted by DMH/DSS.

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

   1. 1. Describe the participant’s choice in

selecting a new Health Home;

1. 2. Provide a brief description of Health

Home services; and

1. 3. Describe the process for the partici-

pant to decline receiving Health Home services from the assigned Health Home provider.

1. (D) Potentially eligible individuals receiving services in the hospital emergency department or as an inpatient will be notified about eligible Health Homes and referred based on their choice of provider. Eligibility for Health Home services will be identifiable through the state’s comprehensive Medicaid electronic health record.
2. (E) Health Home providers to which patients have been auto-assigned will receive communication from the state regarding a patient’s enrollment in Health Home services. The Health Home will notify other treatment providers about the goals and types of Health Home services as well as encourage participation in care coordination efforts.

1. (5) 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. Health Home reimbursement will be

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

1. 3. DMH/DSS reserves the right to make

changes to the payment methodology after consultation with recognized Health Homes and receipt of required federal approvals.

1. (B) Types of Payments.

   1. 1. Clinical Care Management Per Mem-

ber Per Month (PMPM). PMPM reimburses for cost of staff primarily responsible for delivery of Health Home services not covered by other reimbursement and whose duties are not reimbursable otherwise by Medicaid.

AUTHORITY: section 630.050, RSMo Supp. 2011.* Emergency rule filed Dec. 20, 2011, effective Jan. 1, 2012, expired June 28, 2012. Original rule filed Oct. 17, 2011, effective June 29, 2012. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008.