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-92 - Behavioral Health Home Services › Subsection 144-101-II-92.02 - PROVIDER REQUIREMENTS

Current through 2024-29, July 17, 2024
The BHHO and HHP must meet the following requirements.
						Provider must maintain documentation of all processes and procedures described
						below that is available upon request, for review by the Department.
92.02-1
Behavioral Health Home
					 Organization (BHHO)
A. The BHHO must
					 execute a MaineCare Provider Agreement.
B. The BHHO must be approved as a BHHO by
					 MaineCare through the BHHO application process.
C. The BHHO must be a community-based mental
					 health organization, licensed to provide services in the state of Maine, that
					 provides case management to adult and/or children members, is located in the
					 state of Maine, and delivers services through a team-based model of care that
					 includes at least the following personnel.
The Department shall seek and
					 anticipates receiving CMS approval for this Section.
Pending approval,
					 each role must be filled by a different individual. If there is a lapse in
					 fulfillment of team member roles of greater than thirty (30) continuous days,
					 the BHHO must notify the Department in writing and maintain records of active
					 recruitment to fill the position(s).
(1)
Psychiatric Consultant
-shall be a psychiatrist who has current
					 and valid licensure as a physician from the Maine Board of Licensure in
					 Medicine, and who is certified by the American Board of Psychiatry and
					 Neurology Psychiatric medication management or is eligible for examination by
					 that Board as documented by written evidence from the Board, or has completed
					 three (3) years of post-graduate training in psychiatry approved by the
					 Education Council of the American Medical Association and submits written
					 evidence of the training; OR a psychiatric and mental health advanced practice
					 registered nurse (PMH-APRN) who is licensed as a nurse practitioner or clinical
					 nurse specialist by the state of Maine, has graduated from a child and
					 adolescent or adult psychiatric and mental health nurse practitioner, or
					 clinical nurse specialist program, and is certified by the appropriate national
					 certifying body.
The Psychiatric Consultant shall consult with other BHHO
						and primary care professionals and with the member as necessary, to provide
						expertise on the development of evidence-based practices and protocols to the
						BHHO organization.
Under Section
						92, the Psychiatric Consultant
						shall not duplicate any other psychiatric services that may be necessary and
						provided through other sections of the
MaineCare Benefits
						Manual
.
(2)
Nurse Care Manager
- shall be a registered nurse, a psychiatric
					 nurse licensed as a registered professional nurse by the state where services
					 are provided and certified by the American Nurses Credentialing Center (ANCC)
					 as a psychiatric and mental health nurse; a PMH-APRN who is licensed as a nurse
					 practitioner or clinical nurse specialist by the state where services are
					 provided, who has graduated from a child and adolescent or adult psychiatric
					 and mental health nurse practitioner or clinical nurse specialist program, and
					 is certified by the appropriate national certifying body; or an advanced
					 practice nurse, as defined by the Maine State Board of Nursing.
The Nurse Care Manager shall provide primary care
						consultation, psychiatric care consultation, and work with the BHHO, the
						primary care practice and the member to provide other Section
						92 services as necessary, pursuant
						to the Plan of Care.
(3)
Clinical Team Leader
- shall be an independently licensed mental
					 health professional, who may be a physician, physician's assistant,
					 psychologist, a licensed clinical social worker, licensed master social worker
					 conditional II licensed clinical professional counselor, licensed marriage and
					 family therapist, advanced practice registered nurse such as a PMH-APRN; OR,
					 for children's BHH services, a person who was employed on August 1, 2009 as a
					 case management supervisor under the former Section
					 13 of Chapter II of the
MaineCare Benefits Manual
.Such staff shall be considered
					 qualified to serve as a Clinical Team Leader for purposes of this rule.
The Clinical Team Leader shall oversee the development of
						the Plan of Care and direct care management activities across the BHHO, provide
						supervision of Health Home Coordinators and Certified Intentional Peer Support
						Specialists, and ensure that the BHHO meets its requirements as a whole.
(4)
Certified Intentional
					 Peer Support Specialist (CIPSS)
- (for adult services) is an individual
					 who has completed the Maine Office of Behavioral Health (OBH) curriculum for
					 CIPSS, and receives and maintains that certification.
The CIPSS is an individual who is receiving or has
						received services and supports related to the diagnosis of a mental illness, is
						in recovery from that illness, and who is willing to self-identify on this
						basis with BHH members. Peer support staff may function as a CIPSS without
						CIPSS certification for the first nine (9) months of functioning as a CIPSS,
						but may not continue functioning as a CIPSS beyond nine (9) months without:
(a) having received provisional
					 certification by completion of the Core training, and
(b) continuing pursuit of full certification
					 as a CIPSS and maintaining certification as an Intentional Peer Support
					 Specialist according to requirements as defined by SAMHS.
The CIPSS shall coordinate and provide access to Peer
						Support Services, peer advocacy groups, and other peer-run or peer-centered
						services, maintain updated information on area peer services, and shall assist
						the member with identifying and developing natural support
						systems.
(5)
Family or Youth Support Specialist
- (for children's services) is
					 an individual who has completed a designated Maine Office of Child and Family
					 Services (OCFS) curriculum for peer supports and receives and maintains that
					 certification. The Youth Support Specialist is an individual who is receiving
					 or has received services and supports related to the diagnosis of a mental
					 illness, is in recovery from that illness, and who is willing to self-identify
					 on this basis with BHH members.
The Family Support Specialist is an individual who has a
						family member who is receiving or has received services and supports related to
						the diagnosis of a mental illness, and who is willing to self-identify on this
						basis with BHH members. Peer support staff may function as a Family/Youth
						Support Specialist for children's services without certification for the first
						nine (9) months of functioning as a Family/Youth Support Specialist, but may
						not continue functioning as a Family/Youth Support Specialist for children's
						services beyond nine months:
(a)
					 without having received provisional certification by completion of the Core
					 training, and
(b) without
					 continuing pursuit of full certification as a Family/Youth Support Specialist
					 for children's services and maintaining certification as a Family/Youth Support
					 Specialist according to requirements as defined by OCFS.
(6)
Health Home Coordinator for Members
					 with Serious Emotional Disturbance (SED)
-shall be an individual who has
					 a minimum of a Bachelor's Degree from an accredited four (4) year institution
					 of higher learning, with specialization in psychology, mental health and human
					 services, behavioral health, behavioral sciences, social work, human
					 development, special education, counseling, rehabilitation, sociology, nursing,
					 or closely related field; OR who has a Bachelor's Degree from an accredited
					 four (4) year educational institution in an unrelated field and at least one
					 (1) year of full-time equivalent relevant human services experience; OR a who
					 has Master's Degree in social work, education, psychology, counseling, nursing,
					 or closely related field from an accredited graduate school; OR who has been
					 employed since August 1, 2009 as a case manager providing services under
					 Chapter II, Section
					 13 of the
MaineCare
					 Benefits Manual.
The SED Health Home Coordinator shall draft the Plan of
						Care for each SED member utilizing a Child and Adolescent Needs and Strengths
						assessment tool (CANS) information, implement that Plan of Care and the
						coordination of services, and support and encourage members inactively
						participating in reaching the goals set forth in their Plan of Care.
Each member shall have only one Health Home Coordinator
						and cannot be enrolled in more than one case management program funded by
						Medicaid.
(7)
Health
					 Home Coordinator for Members with Serious and Persistent Mental Illness
					 (SPMI)
- shall be an individual who is certified by the Department as a
					 Mental Health Rehabilitation Technician/Community (MHRT/C).
The SPMI Health Home Coordinator shall draft the Plan of
						Care for each member, oversee that Plan of Care and the coordination of
						services, and support and encourage members in actively participating in
						reaching the goals set forth in their Plan of Care.
Each member shall have only one Health Home Coordinator
						and cannot be enrolled in more than one case management program funded by
						Medicaid.
(8)
Medical
					 Consultant
- shall be a physician licensed by the State of Maine to
					 practice medicine or osteopathy, a physician's assistant licensed as such by
					 the State of Maine, or a certified nurse practitioner who meets all of the
					 requirements of the licensing authority of the State of Maine.
The Medical Consultant shall collaborate with other
						providers of BHHO and primary care services (at least 4 hours/month per 200
						members or pro-rated for agencies that serve fewer than 200 clients) to select
						and implement evidence-based clinical initiatives, lead quality improvement
						efforts, evaluate progress, and convene provider clinical quality improvement
						meetings.
D. The
					 BHHO must a there to licensing standards in documentation of all its BHHO
					 providers' qualifications in their personnel files. Pursuant to applicable
					 licensing standards, the BHHO must have a review process to ensure that
					 employees providing BHHO services possess the minimum qualifications set forth
					 above.
E. The BHHO must be
					 co-occurring capable, meaning that the organization is structured to welcome,
					 identify, engage and serve individuals with co-occurring substance use and
					 mental health disorders and to incorporate attention to these issues into
					 program content.
F. The BHHO must
					 have an executed contract or Memorandum of Agreement with at least one (1) HHP
					 in its area that describes procedures and protocols for regular and
					 systematized communication and collaboration across the two agencies, the roles
					 and responsibilities of each organization in service delivery, and other
					 information necessary to effectively deliver, pay and receive reimbursement for
					 all BHH services to all shared members without duplication. This may include
					 names and contact information of key staff at the BHHO and HHP, acceptable
					 mode(s) of electronic communication to ensure effective and privacy-protected
					 exchange of health information, frequency of communication at both leadership
					 and practice levels (e.g., weekly, monthly, quarterly), procedures for
					 bi-directional access to member Plan of Care and other health information,
					 referral protocols for new members, collaboration on treatment plans and member
					 goals and, as needed, Business Associate Agreement/Qualified Service
					 Organization addenda.
G. The BHHO
					 musthavean EHR system and an EHR for each member.
H. The BHHO shall have in place processes,
					 and procedures, and member referral protocols with local inpatient facilities,
					 Emergency Departments (ED), child/adult residential facilities, crisis
					 services, and corrections for prompt notification of an individual's admission
					 and/or planned discharge to/from one of these facilities or services. The
					 protocols must include coordination and communication on enrolled or
					 potentially eligible members, The BHHO shall have systematic follow-up
					 protocols to assure timely access to follow-up care.
I. The BHHO shall ensure that it has policies
					 and procedures in place to ensure that the Health Home Coordinator can
					 communicate changes in patient condition that may necessitate treatment change
					 with treating clinicians, on an as needed basis.
J. The BHHO must participate in BHH technical
					 assistance opportunities, as determined by the Department. At least one (1)
					 member of the care team described in 92.02-1(C) must engage in these
					 opportunities.
K. Within the first
					 six (6) months following the start of the BHHO's participation, the BHHO shall
					 obtain a written site assessment from the Department or its authorized entity,
					 to establish a baseline status in meeting the Core Standards (92.02-1 (L)) and
					 identify the BHHO's training and educational needs.
L. For the first year of participation, the
					 BHHO must submit quarterly reports on progress towards implementing the Core
					 Standards. Within one year of the BHHO's participation, the BHHO must fully
					 implement the Core Standards.
Once Core Standards are fully implemented, the BHHO may
						request the Department's approval to submit the Core Standard progress report
						annually instead of quarterly.
The Core Standards are:
(1)
Demonstrated Leadership
-
					 The BHHO identifies at least one (1) Clinical Team Leader within the BHHO who
					 implements and oversees the Core Standards.
The Clinical Team Leader(s) work with other providers and
						staff in the BHHO to build a team-based approach to care, continually examine
						the processes and structures to improve care, and review data on the
						performance of the BHHO.
(2)
Team-Based Approach to Care
- The BHHO has implemented a
					 team-based approach to care delivery that includes expanding the roles of
					 non-licensed team professionals and includes CIPSS as leaders and partners in
					 the provision of care.
The BHHO utilizes non-licensed staff to improve access,
						efficiency, and member engagement in specific ways, including one or more of
						the following:
(a) Through clear
					 identification of roles and responsibilities;
(b) Training on and integration of CIPSS as
					 meaningful partners in service delivery;
(c) Regular team meetings.
(3)
Population Risk
					 Stratification and Management
- The BHHO has adopted processes to
					 identify and stratify members across their population who are at risk of
					 adverse outcomes and adopted procedures that direct resources or care processes
					 to reduce those risks.
For purposes of this provision, "adverse outcomes" means
						hospitalization, institutionalization, involvement with law enforcement, job
						loss or home loss, which occur as a result of the member's SPMI or SED.
(4)
Enhanced Access
-
					 The BHHO enhances access to services for their members, including:
(a) The BHHO has a system in place, such as
					 an on call or answering service, for BHH members to reach a member of the
					 organization or an authorized entity twenty-four (24) hours a day, seven (7)
					 days a week to address and triage the members' needs.
(b) The BHHO has processes in place to ensure
					 twenty-four (24) hours a day, seven (7) days a week access to BHH member
					 records.
(c) The BHHO has processes
					 in place to monitor and ensure this enhanced access to care.
(5)
Comprehensive
					 Consumer/Family Directed Care Planning
- The BHHO has processes in place
					 to ensure that consumer voice and choice is reflected in Plan of Care
					 development. These processes include:
(a)
					 Wraparound principles for children with SED and their families.
(b) Practice guidelines for recovery-oriented
					 care.
(6)
Behavioral-Physical Health Integration
- The BHHO has completed a
					 baseline assessment of its behavioral-physical health integration capacity
					 during its first year of participation as a BHHO. Using results from this
					 baseline assessment, the BHHO has implemented one or more specific improvements
					 to integrate behavioral and physical health care.
(7)
Inclusion of Members and
					 Families
- The BHHO includes members and their family as documented and
					 regular participants at leadership meetings, and/or the BHHO has in place a
					 member-driven process to identify needs and solutions for improving services.
(a) The BHHO has processes in place to
					 support members and families to participate in these leadership and/or advisory
					 activities (e.g., on the agency's Board of Directors, involvement in internal
					 advisory committees that solicit and support the engagement of consumers and
					 families in identifying needs and solutions, etc.);
(b) The BHHO has implemented systems to
					 gather member and family input at least annually (through mail surveys, phone
					 surveys, point of care questionnaires, focus groups, or other methods);
					 and
(c) The BHHO has processes in
					 place to design and implement changes that address needs and gaps in care
					 identified via member and family input.
(8)
Connection to Community Resources
					 and Social Support Services
- The BHHO has processes in place to
					 identify and make referrals to local community resources and social support
					 service, including those that provide support in self-management, to assist
					 members in overcoming barriers to care and meeting health and recovery
					 goals.
(9)
Commitment to
					 Reducing Waste, Unnecessary Healthcare Spending, and Improving Cost-Effective
					 Use of Healthcare Services
- The BHHO has processes in place to reduce
					 wasteful spending of healthcare resources and improving the cost-effective use
					 of healthcare services, as evidenced by at least one initiative that targets
					 waste reduction, such as:
(a) Reducing
					 avoidable hospitalizations;
(b)
					 Reducing avoidable ED visits;
(c)
					 Working with specialists to develop new models of specialty consultation that
					 improve member experience and quality of care, while reducing unnecessary use
					 of services; and
(d) Directing
					 referrals to specialists who consistently demonstrate high quality and
					 cost-efficient use of resources.
(10)
Integration of Health Information
					 Technology
- The BHHO uses an electronic data system that includes
					 identifiers and utilization data about members. Member data is used for
					 monitoring, tracking and indicating levels of care complexity for the purpose
					 of improving member care.
The system is used to support member care, including one
						or more of the following:
(a) The
					 documentation of need and monitoring clinical care
(b) Supporting implementation and use of
					 evidence-based practice guidelines;
(c) Developing Plans of Care and related
					 coordination; and
(d) Determining
					 outcomes (e.g., clinical, functional, recovery, satisfaction, and cost
					 outcomes).