Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-91 - Physician Services › Subsection 144-101-II-91.02 - GENERAL REQUIREMENTS FOR CCTs AND HOME PROVIDERS

Current through 2024-29, July 17, 2024
CCTs and HOME Providers shall meet the requirements set
						forth in this Section.
Both CCTs and HOME Providers shall:
1. Execute a MaineCare Provider
					 Agreement;
2. Complete a CCT
					 application and be approved as a CCT by MaineCare;
3. Have an operational EHR;
4. Participate in Department-required CCT or
					 HOME Provider technical assistance and educational opportunities on an annual
					 basis. At least one (1) person in each CCT and HOME Provider must engage in
					 these opportunities;
5.
Meet
					 Core Standards.
CCTs and HOME Providers shall demonstrate how they
					 intend to meet the following Core Standards prior to approval to provide
					 services. Within the first three (3) months from the start of the CCTs' and
					 HOME Providers' participation, they shall participate in an on-site assessment
					 initiated by the Department, or its authorized agent, to establish their
					 baseline performance in regards to meeting the Core Standards, and to identify
					 the CCTs' and HOME Providers training and educational needs.
For the remainder of the first year of participation, the
						CCTs and HOME Providers shall submit quarterly reports on sustained
						implementation of the Core Standards. After the first year, the CCTs and HOME
						Providers may request the Department's approval to submit the Core Standard
						progress report annually instead of quarterly. The progress report shall
						compare CCT and HOME Providers progress to the baseline.
a.
Demonstrated Leadership
-
					 CCTs and HOME Providers shall identify at least one individual as a leader
					 within the care team who champions the implementation and continued maintenance
					 of the Core Standards.
b.
Team-Based Approach to Care
- CCTs and HOME Providers shall
					 implement a team-based approach to comprehensive care management, coordination,
					 and supports that includes expanding the roles of non-billable professionals
					 (e.g. nurses, medical assistants, peer support staff, CHWs, and/or housing
					 navigators). CCTs and HOME Providers shall review policies, procedures, data,
					 and structures to improve care delivery, access, efficiency, and Member
					 engagement in specific ways, including two or more of the following:
i. Identifying roles and responsibilities
					 across care team members;
ii.
					 Training on and integration of non-licensed team professionals as meaningful
					 partners in service delivery;
iii.
					 Holding regular team meetings;
iv.
					 Expanding Member education and support opportunities; and
v. Providing greater data support to enhance
					 the quality and cost-effectiveness of CCT and HOME Providers
					 services.
c.
Population Risk Stratification and Management
- CCTs and HOME
					 Providers shall adopt processes internally and with external partners (e.g.
					 primary care practices, behavioral health providers, social service agencies)
					 to identify and stratify patients who are at risk for adverse outcomes and
					 shall adopt procedures that direct resources or care processes to reduce those
					 risks. CCTs and HOME Providers shall utilize predictive analytics and/or risk
					 models based on clinical, demographic, social, and/or other model inputs. CCTs
					 and HOME Providers shall retain risk assessment documentation in the Member's
					 record.
"Adverse outcomes" includes, but is not limited to, loss
						of housing, incarceration, or a negative clinical outcome and/or avoidable use
						of healthcare services such as crisis services, hospital admissions, and/or
						emergency department visits.
d.
Enhanced Access
-The CCTs and
					 HOME Providers shall enhance access to services for their population by:
i. Ensuring access to Member records
					 twenty-four (24) hours a day, seven (7) days a week;
ii. Implementing processes to monitor and
					 ensure access to care, e.g. from referral to intake; and
iii. Following up on Member inquiries within
					 one (1) business day of the Member's inquiry.
e.
Integrated Care Management
-
					 CCTs and HOME Providers shall have policies and procedures in place to provide
					 care management services for patients at high risk of experiencing adverse
					 outcomes. Care management staff shall have clear roles and responsibilities,
					 receive explicit training to provide care management services, and have
					 processes for tracking outcomes for patients receiving care management
					 services. CCTs and HOME Providers shall contribute to health management
					 strategies and planning processes with their clinical and community
					 partners.
f.
Behavioral and
					 Physical Health Integration
- Annually, CCTs and HOME Providers shall
					 submit a completed assessment of their Behavioral and Physical Health
					 Integration progress and identify an area of focus for the following
					 twelve-(12) month period to improve Behavioral and Physical Health Integration.
					 The assessment tool will be provided by the Department.
g.
Inclusion of Members and
					 Families
-CCTs and HOME Providers shall include and document Members and
					 family members as regular participants at leadership meetings or in
					 committees/meetings to advise leadership on patient-centered needs and
					 solutions to improve services.
CCTs and HOME Providers shall implement systems to gather
						Member and family input at least annually (e.g. via mail survey, phone survey,
						point of care questionnaires, focus groups, etc.). CCTs and HOME Providers
						shall have a process in place to design and implement changes that address
						needs and gaps in care identified via Member and family input.
h.
Connection to Community
					 Resources and Social Support Services
- CCTs and HOME Providers shall
					 have processes in place to identify local community resources and social
					 support services, including those that provide self-management support to
					 assist Members overcome barriers to care and meet health goals and
					 health-related social needs.
i.
Commitment to Reducing Waste, Unnecessary Healthcare Spending, and
					 Improving Cost-effective Use of Healthcare Services
- CCTs and HOME
					 Providers shall implement processes to reduce wasteful spending on healthcare
					 resources and to increase the cost-effective use of healthcare services as
					 evidenced by at least one initiative that targets waste reduction from the
					 following list:
i. Reducing avoidable
					 hospitalizations;
ii. Reducing
					 avoidable emergency department visits;
iii. Reducing avoidable escalation of service
					 needs such as crisis, residential, and inpatient stays;
iv. Directing referrals to medical and/or
					 behavioral health specialists who consistently demonstrate and document high
					 quality and cost-efficient use of resources.
j.
Integration of Health Information
					 Technology
- CCTs and HOME Providers shall use an electronic data system
					 that includes identifiers and utilization data about patients. Member data is
					 used for monitoring, tracking, and indicating levels of care complexity for the
					 purpose of improving patient care.
The system is used to support Member care, including one
						or more of the following:
i. The
					 documentation of need and monitoring of clinical care;
ii. Supporting implementation and use of
					 evidence-based practice guidelines;
iii. Developing plans of care and related
					 coordination; or
iv. Determining
					 outcomes (e.g. clinical, functional, satisfaction, and cost outcomes); or
v. Assessing risk (e.g. predictive
					 analytics, risk scores/models).