# Form_01

Question:
Forms and Documents - Check in Attached Documents


Question:
The 5055 and Member Bill of Rights are reviewed and the Comprehensive Assessment is updated with the member, annually (as evidenced on the Annual Acknowledgement form).


Question:
At the time of POC review, is there a signed acknowledgment form to evidence member participation in the plan update (or clear documentation as to why the member could not participate, such as an update when in DSE).


Question:
If the member was enrolled, is the DOH 5234 form completed and scanned in file. (Form DOH 5234 notifies the member of their Health Home enrollment. The notice should be mailed to the member along with the Health Home welcome letter.)


Question:
If the member was found to be ineligible prior to enrollment, is the DOH 5236 form completed and scanned in file. (It explains that they did not meet the criteria for enrollment and the reason for denial of enrollment.)


Question:
Signed copy of Bill of Rights scanned into EMR and completed correctly (from enrollment).


Question:
Scanned documentation shows clear evidence of eligibility (contains documentation of a serious mental illness or HIV/AIDS or two of the following: mental health condition, substance abuse disorder, asthma, diabetes, heart disease, BMI > 25 or other).


Question:
A copy of the most recent and active AOT order is scanned into the documents of the chart.


Question:
Does the member have clear evidence of HH+ eligibility? (Current Eligibility form and Medical Records showing evidence are in the uploaded documents.)


Question:
If the member was discharged due to ineligibility, inappropriateness, or DSE, was the 5235 sent 10 days prior to closing. (Notice by means of Form DOH-5235 is required before the Health Home can disenroll.)


Question:
If the HARP eligibility assessment was done, then an attached document contains the summary of the eligibility assessment/reassessment.


Question:
If the eligibility assessment was completed and the member was interested in service, was there evidence that the LOSDR (service determination request/ the Preliminary Plan of Care) was sent to the MCO. (Uploaded request to documents.)


Question:
If notes indicated a LOSD response was received from the MCO, a copy of the MCO response is in the documents.


Question:
If member has an LOSD from the MCO and is linked to services, then the full HARP POC is completed and a copy is attached in the documents.


# Form_02

Question:
Consent Form - Check in Attached Documents


Question:
Is the HIXNY consent entered correctly in CareManager. (Electronic HIE)? (Unless the member denies/withdraws consent.)


Question:
DOH-5055 Member Information Sharing Consent Form Completed Correctly (On the current/most recent 5055)?


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


Question:
Consent In Action - Determined when reading Notes


Question:
Updated copies of 5055 present when changes are made (changes in providers, supports, etc.).


Question:
The Member's PHI and confidentiality was kept. No coordination with entities or individuals outside of those named on the consent form is present in the EMR (i.e. there is no evidence of a PHI or confidentiality breach).


# Form_03

Question:
Engagement activities are clearly documented as being meaningful and progressive in nature. (More than one attempt, reasonable timeframes between attempts, evidence of alternative means of locating member, use of MCO, referent, and other resources.)


Question:
If the member was enrolled, is the DOH 5234 form completed and scanned in file. (Form DOH 5234 notifies the member of their Health Home enrollment. The notice should be mailed to the member along with the Health Home welcome letter.)


Question:
If the member was found to be ineligible prior to enrollment, is the DOH 5236 form completed and scanned in file. (It explains that they did not meet the criteria for enrollment and the reason for denial of enrollment.)


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# Form_04

Question:
Scanned documentation shows clear evidence of eligibility (contains documentation of a serious mental illness or HIV/AIDS or two of the following: mental health condition, substance abuse disorder, asthma, diabetes, heart disease, BMI > 25 or other).


Question:
If scanned records are present, do the diagnoses/problems captured in EMR match those in the member's records.


Question:
Member Information on demographics tab appears complete. (Language, Race, Gender, etc.)


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


Question:
Signed copy of Bill of Rights scanned into EMR and completed correctly (from enrollment).


Question:
Completed intake assessment prior to or at the time of enrollment.


Question:
The Intake Assessment is completed appropriately and reflects current member needs. (Includes needs identified on the referral, in notes, or related to the members primary diagnosis, etc.)


# Form_05

Question:
The 5055 and Member Bill of Rights are reviewed and the Comprehensive Assessment is updated with the member, annually (as evidenced on the Annual Acknowledgement form).


Question:
Initial Comprehensive assessment is done within 30 days of enrollment.


Question:
Annual Reassessment: Comprehensive assessment is done annually. If not completed in on time, documentation clearly shows reason for delay and efforts made to coordinate with member.


Question:
Annual comprehensive assessments are completed appropriately (in person with the Member and reflect current needs / updates).


Question:
The SDOH Assessment is done with the member, annually. (As of 2023.)


Question:
CAGE-AID completed on all members at the time of the initial comp assessment.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# Form_06

Question:
The plan of care is completed within 30 days of completion of the initial assessment OR within 60 days of enrollment.


Question:
The plan of care is reviewed at least annually, using the Annual plan type in CareManager. (As of 2023.)


Question:
The plan of care is completed face to face.


Question:
At the time of POC review, is there a signed acknowledgment form to evidence member participation in the plan update (or clear documentation as to why the member could not participate, such as an update when in DSE).


Question:
If the POC was updated without the member present (such as when the member is in DSE), then are efforts made to engage the member in updating the POC once the member is reconnected with service. (POC is updated and acknowledgment form signed.)


Question:
Member strengths and barriers to care are identified on the plan of care. (This should match or relate to the strengths/barriers from the comp assessment or more recent ones that the member has identified and are documented in the notes.)


Question:
Is there evidence that the care plan is being updated for significant events and as needs change? (i.e. If new issues or goals arise, goals met, or discontinued are those changes being reflected in the plan of care?)


Question:
Interventions are clear, concrete, achievable activities for the member. Interventions can be maintenance, such as 'continue to ___' but should also have small achievable steps when applicable.


Question:
The plan of care timeframes are realistic; not all set to same date range such as 6 months out. Six month timeframes are acceptable for ongoing maintenance interventions.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.) The Plan of Care contains a Physical or Behavioral Health Objective.


Question:
The Plan of Care includes all categories of service listed in the court-ordered AOT treatment plan.


Question:
Did the plan of care include objectives related to the reason the member qualifed for HH+ services?


# Form_07

Question:
The plan of care addresses all identified needs unless clearly documented as resolved. (Needs from assessments, referral, notes, etc.)


Question:
.--- Need for primary care services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for home care services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for physical rehab services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for SUD services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for mental health services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for HIV/AIDS services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for housing is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for transportation is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for food is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Financial needs are addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for wellness and prevention services is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for specialty services (dental, podiatry, etc.) is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for advance directive information if identified as a need on the assessment. (Objective/Interventions/Timeframes)


Question:
.--- Objectives related to education (School) is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Objectives related to employment is addressed in the care plan. (If needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for ANY OTHER IDENTIFIED SERVICES if identified as a need are addressed in the care plan. (Objective/Interventions/Timeframes)


# Form_08

Question:
A minimum of one monthly core service for the member is documented. If not, then there is documentation of why no core service was provided. (Member out of area, refusal by member, etc.)


Question:
If 60 days passed with no contact with the member, were they placed in diligent search? If the member was placed in diligent search prior to 60 days, were there at least 30 days with no contact despite meaningful attempts to contact?


Question:
(Above Diligent Search question does not apply to members who are incarcerated or in an excluded setting (extended) hospitalization.)


Question:
HML billing assessment correctly reflects billable services rendered.


Question:
On the member's current (most recent HML), for questions 3 through 8 was supporting documentation present when needed. (Uploaded into the member's chart.)


Question:
If member identified cultural preferences that they wanted addressed or acted on, those cultural preferences identified are addressed and acted upon as needed? (As evidenced in notes.)


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist.) (i.e. If member requested to change providers, when a referral to a provider is made, was the member is given choices?


# Form_09

Question:
Care is member-centered. Activities are centered on member needs. (Activities reflect the goals and objectives in the care management plan.)


Question:
.--- If a member identified family/caregiver involvement, have member preferences been acted upon? (E.g. member wants updates to mother, is there evidence in the chart to support the mother receiving updates?)


Question:
.--- If member was able to begin managing self care, did the care coordination promote member independence. (i.e. CC teaches the member how to set up MAS vs making all MAS calls.) (Activities are proactive and promote empowerment.)


Question:
.--- Documentation reflects that care management team advocated for services and assisted with scheduling of needed services. Did the Care Coordinator follow-up on missed appointments and problem solve with member on making future appointments?


Question:
.--- Barriers identified in the plan of care are addressed and acted upon as needed (as evident in notes).


Question:
.--- Over the past year, is there evidence that the CC is addressing all objectives from the plan of care with the member. If not, is there evidence that the CC has reasonably attempted to address objectives?


Question:
.--- Follow up on member issues are evident. (i.e. If member asked for assistance, did the care coordinator offer assistance and follow up to ensure needs were met.)


Question:
.--- If the notes indicate next steps for the Care Coordinator, then those next steps are documented. If the CC stated they would make a call or meeting was there documentation that those contacts took place (or documentation why they did not).


Question:
.--- Frequency of contact with the member was appropriate based on member needs. (i.e. If member had immediate complex needs such as an eviction did the care coordinator make additional contacts to ensure members needs were met.)


Question:
.--- If member went into crisis, documentation reflects crisis intervention activities. (Medical or Behavioral Health.)


Question:
.--- Based on individual needs and preferences, The care coordinator promotes wellness and prevention by linking the member with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services.


# Form_10

Question:
Was the MCO notified when the Member experienced barriers to service or when the Member experienced a significant event or change in status that would impact Member care (i.e., suicide attempt, housing disruption, step on or off HH+ services, etc.)?


Question:
Notes contain evidence of attempts to collaborate care with member's treatment team when appropriate. (i.e. If member reports feelings of suicidality  was the mental health provider notified.)


Question:
Case Conferences and Team Meetings are held when appropriate (per policy guidance).


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


Question:
If 60 days passed with no contact with the member, were they placed in diligent search? If the member was placed in diligent search prior to 60 days, were there at least 30 days with no contact despite meaningful attempts to contact?


Question:
(Above Diligent Search question does not apply to members who are incarcerated or in an excluded setting (extended) hospitalization.)


Question:
Was the Member's MCO notified of the status change, if applicable, during the first month of DSE?


Question:
Was the POC updated to reflect Diligent search activities that were relevant to the member?


Question:
If the POC was updated without the member present (such as when the member is in DSE), then are efforts made to engage the member in updating the POC once the member is reconnected with service. (POC is updated and acknowledgment form signed.)


Question:
Did the number of diligent search activities meet the minimum requirement to bill? (At least 3 different efforts.)


Question:
Were diligent search activities meaningful, progressive, and diverse?


Question:
If the Member was located while in DSE, did a conversation occur to attempt to re-engage the Member in Health Home Services?


# Form_11

Question:
The HARP Program type is correctly identified in the chart.


Question:
Staff perform HARP eligibility assessment or core referral at least annually or when there is a significant change in status for HARP (or notes indicate HARP services were declined).


Question:
If the eligibility assessment was completed and the member was interested in service, was there evidence that the LOSDR (service determination request/ the Preliminary Plan of Care) was sent to the MCO. (Uploaded request to documents.)


Question:
If notes indicated a LOSD response was received from the MCO, a copy of the MCO response is in the documents.


Question:
If member has an LOSD from the MCO, Is there documentation that steps were made to link the member to HCBS services.


Question:
If member has an LOSD from the MCO and is linked to services, then the full HARP POC is completed and a copy is attached in the documents.


Question:
Was a CareManager 'General Assessment' done for each key HARP activity noting the HARP activity done. Each key HARP activity should have both a note documenting the encounter and a General Assessment.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# Form_12

Question:
Was the member assigned to the HH+ program type in Care Manager?


Question:
Does the member have clear evidence of HH+ eligibility? (Current Eligibility form and Medical Records showing evidence are in the uploaded documents.)


Question:
For HIV HH+, at 6 months, a review of the POC and HIV assessment took place F2F at the members home. This included an eval of viral load and progress towards the objectives. This re-assessment of progress and status is written as a CM Note.


Question:
For HIV HH+, at six months a case conference took place with consented providers.


Question:
Did documentation in chart reflect a need for HH+ services? (Member meets acuity and appropriatness criteria for the HH+ program.)


Question:
Did the plan of care include objectives related to the reason the member qualifed for HH+ services?


Question:
Were the minimum core service delivery requirements met? (Member received at least 2 F2F core services and 2 other core services in the month.) If not, were actions taken to attempt to deliver core services.


Question:
Was the contact type and amount of contact appropriate based on member acuity. (For example, if member had acute needs that required more than two F2F core services, were core services delivered to ensure needs were met.)


Question:
The HH+ rate was only billed when appropriate.


Question:
Does the HH+ qualifying category on the HML match documented eligibility criteria?


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# Form_13

Question:
A copy of the most recent and active AOT order is scanned into the documents of the chart.


Question:
The AOT member is identified as such in the Programs section of CareManager.


Question:
The Plan of Care includes all categories of service listed in the court-ordered AOT treatment plan.


Question:
The AOT member received 4 face to face core services per month (with documentation if unable to achieve).


Question:
If the AOT member was considered missing (no credibly reported contact within 24 hours of the Care Coordinator receiving notice that the person had an unexplained absence from an apt), were appropriate steps taken to seek out the member?


Question:
If the AOT member was considered missing (per above), was a missing persons report filed with the police within 24-48 hours?


Question:
Was there evidence of collaboration with providers identified in AOT Tx Plan, especially around non compliance with AOT Treatment Plan services?


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# Form_14

Question:
Answer these questions for general ER / hospitalizations (will not be scored for high utilizers).


Question:
Care Coordinator responded to alerts of hospitalizations and ED visits – and any other events calling for the provision of Care Transition services within 2 business days of receiving the alert.


Question:
If reason for the visit could have been handled by primary care or urgent care, was the member given education regarding appropriate use of the emergency room.


Question:
Is there evidence that the care plan is being updated for significant events and as needs change? (i.e. If new issues or goals arise, goals met, or discontinued are those changes being reflected in the plan of care?)


Question:
If the ER visit or Hospitalization required aftercare such as a new provider, follow up appointments, changes in medications, etc. Then also answer the following.


Question:
Care coordinator assists member in following their discharge plan when transitioning back to the community.


Question:
.--- Discharge instructions from ER visits and hospitalizations are obtained and used to help member transition back to the community; appointments kept, meds obtained, etc. If not, does documentation show an attempt to obtain the discharge plan.


Question:
.--- Documentation shows that the care coordinator notified/collaborated with the care team upon notification of member’s transition to/from an ER/hospital/residential/rehabilitative setting (Providers/MCO).


Question:
.--- If member has social supports, support resources and persons were identified with member to assist in the time of crisis and aide in preventing future crisis.


Question:
.--- If member transitioned between criminal justice or any inpatient setting, was a warm handoff facilitated or an attempt to facilitate was documented. For inpatient stays, did the Care Coordinator attemped to collaborate with staff?


Question:
For Members Who are Considered High Utilizers


Question:
Care coordinator works with member to address barriers and root cause for repeat ER/IP utilization. (Such as connecting with outpatient care, meeting SDOH needs.)


Question:
Was there ongoing case collaboration with care team members (outside of formal case conferencing) to help address member needs and reduce utilization?


Question:
Is the member's high utilization addressed on the Plan of Care?


Question:
Case Conferences and Team Meetings are held when appropriate (per policy guidance).


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# Form_15

Question:
For all discharges, was the required discharge letter completed and sent to the member. If not, is there documentation of  why it could not be sent (i.e. no address).


Question:
If the member was discharged due to ineligibility, inappropriateness, or DSE, was the 5235 sent 10 days prior to closing. (Notice by means of Form DOH-5235 is required before the Health Home can disenroll.)


Question:
Does the reason for discharge selected reflect the reason for discharge in the discharge summary and notes.


Question:
For Members who were able to be contacted regarding the discharge, was the discharge discussed with the member prior to discharge to prepare member and ensure discharge readiness.


Question:
A discharge summary was completed for the discharge. This discharge summary contains a detail of events leading up to the discharge.


Question:
Was the summary shared or communicated to the care team members? (PCP, Mental Health Provider, Housing, MCO, etc.)


Question:
If there were unmet needs and discharge was able to be discussed with the member, was there evidence of discharge plan from Health Home program including referrals to services or programs.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


# FormFeeder_LookUpID

Backup_Loc:
W:\CRHC HH Admin\Quality Assurance\Auditors - Working Folder\Jon's Audit Folder\Audit Tool Backups


# Interpretive_Guidance

Question:
Scanned documentation shows clear evidence of eligibility (contains documentation of a serious mental illness or HIV/AIDS or two of the following: mental health condition, substance abuse disorder, asthma, diabetes, heart disease, BMI > 25 or other).

Blue Example:
If documentation is uploaded and contains evidence of eligibility criteria.

Red Example:
If documentation is not present to prove eligibility. *Immediate report out


Question:
If scanned records are present, do the diagnoses/problems captured in EMR match those in the member's records.

Interpretive Guidance:
1. *Leave a comment if neccesaryCS-Enrolled cases only looking for qualifying dx to be listed. Approach fully enrolled cases the same as always- with qualifying and relevant dx listed. 2. Give full credit if there was something in the problems tab, but not in the uploaded medical records.

Blue Example:
If the CC had captured all of the qualifying diagnoses in the Problems Tab.

Green Example:
Use your judgement between green/yellow scoring--were there diagnoses left out of CareManager that had a 'trickle down effect'? Was the POC impacted by any diagnoses being overlooked?

Yellow Example:
Use your judgement between green/yellow scoring--were there diagnoses left out of CareManager that had a 'trickle down effect'? Was the POC impacted by any diagnoses being overlooked?

Red Example:
If the CC had failed to capture the qualifying diagnoses

N/A Example:
Scanned records are not present. *Immediate report out


Question:
Member Information on demographics tab appears complete. (Language, Race, Gender, etc.)

Interpretive Guidance:
Must include at least Language, Race, and Gender

Blue Example:
All correct (language, race, gender are completed)

Yellow Example:
If one or two out of the three underlined in column J (Language, Race, and Gender) are missing.

Red Example:
If language, race, and gender are not completed.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)

Red Example:
If there was a separate issue that is not pertenant to the above questions, score red and/or leave a comment. *Bring to huddle or supervision if uncertain of reason for scoring red.


Question:
Consent Form - Check in Attached Documents


Question:
Is the HIXNY consent entered correctly in CareManager. (Electronic HIE)? (Unless the member denies/withdraws consent.)

Interpretive Guidance:
1. Still current guidance for 2023 (until DOH changes)2. Hixny accepts the 5055 as a valid form of consent for Hixny. If a 5055 is on file, the Electronic HIE must be entered for full credit.  If it is not entered, score red and note as an issue.3. If a separate Hixny consent form is completed, and marks the Member denies consent, then the Electronic HIE should not be entered in CareManager (overrides Hixny consent provided on page 1 of 5055)

COVID Temporary Guidance:
1. October 26, 2020: Written consents required within 60 days of Enrollment (NEW Enrollments ONLY)2. April 1, 2021: Verbal Consents permitted

Blue Example:
5055 is on file and Electronic HIE is entered

Yellow Example:
1. COVID: Past 60 days mark and no written consent BUT collaboration.

Red Example:
1. If Electronic HIE is entered and a separate Hixny form is present that denies consent (immediate report out)2. If the 5055 is on file and Electronic HIE is not entered.3. COVID: Past 60 day mark and no written consent BUT no collaboration.


Question:
DOH-5055 Member Information Sharing Consent Form Completed Correctly (On the current/most recent 5055)?

Interpretive Guidance:
Leave a comment regarding specific issues noted

Blue Example:
Calculated based on scores from roll-up questions.

Green Example:
Calculated based on scores from roll-up questions.

Yellow Example:
Calculated based on scores from roll-up questions.

Red Example:
Calculated based on scores from roll-up questions.


Interpretive Guidance:
Examples: Prefilled lines for MCO, dental provider, preferred pharmacy, emergency contact, preferred hospital.

Red Example:
1. If prefilled lines on page 3 are left blank and initialed/dated. (Example, prefilled line for MCO doesn't list insurer). *Leave comment2. If there was a separate issue that is not pertenant to the above questions, score red and/or leave a comment. *Bring to huddle or supervision if uncertain of reason for scoring red.


Question:
Consent In Action - Determined when reading Notes


Question:
Updated copies of 5055 present when changes are made (changes in providers, supports, etc.).

Blue Example:
Changes to consents were warranted and reflected on the 5055.

Yellow Example:
1. Changes to consents were needed, but only some were reflected on the 5055. 2. If the Member provided verbal consent and there was an opportunity to collect written consent, but was not obtained.

Red Example:
Changes to consents were needed, but none were reflected on the 5055.


Question:
The Member's PHI and confidentiality was kept. No coordination with entities or individuals outside of those named on the consent form is present in the EMR (i.e. there is no evidence of a PHI or confidentiality breach).

Interpretive Guidance:
Leave comment in audit with details of findings.

Blue Example:
If collaboration occurred, consent was present, and confidentiality was kept.

Yellow Example:
If collaboration occurred, written consent was not obtained, but Members were aware of the interaction (leave a comment in tool w/specifics, add to immediate report outs)

Red Example:
If collaboration occurred, written consent was not obtained, and the Member was not aware of the interaction (leave a comment, add to immediate report outs)

N/A Example:
If no collaboration with consented parties was present.


Question:
Engagement activities are clearly documented as being meaningful and progressive in nature. (More than one attempt, reasonable timeframes between attempts, evidence of alternative means of locating member, use of MCO, referent, and other resources.)

Blue Example:
Good variety of efforts which are meaningful to the Candidate's status (i.e if homeless or hospitalized).

Red Example:
Same engagement activity utilized (calling non-working number) or no activities at all.


Question:
Outreach Forms (Separate by Opt-out vs Enrolled)


Question:
If the member was enrolled, is the DOH 5234 form completed and scanned in file. (Form DOH 5234 notifies the member of their Health Home enrollment. The notice should be mailed to the member along with the Health Home welcome letter.)

Blue Example:
DOH 5234 completed and uploaded to chart

Yellow Example:
Note documentation reflects DOH 5234 was completed but not uploaded to chart (leave a comment)


Question:
If the member was found to be ineligible prior to enrollment, is the DOH 5236 form completed and scanned in file. (It explains that they did not meet the criteria for enrollment and the reason for denial of enrollment.)

Blue Example:
DOH 5236 completed and uploaded to chart

Yellow Example:
Note documentation reflects DOH 5236 was completed but not uploaded to chart (leave a comment)


Interpretive Guidance:
1. After May 1, 2022, do not ding for the absence of the DOH 5059 (not used anymore).


Question:
Signed copy of Bill of Rights scanned into EMR and completed correctly (from enrollment).

Yellow Example:
Note documentation reflects BOR was completed but not uploaded to chart (leave a comment)


Question:
Completed intake assessment prior to or at the time of enrollment.

Blue Example:
Completed at the time of enrollment or notes clearly show a reason for delay


Question:
The Intake Assessment is completed appropriately and reflects current member needs. (Includes needs identified on the referral, in notes, or related to the members primary diagnosis, etc.)


Question:
The 5055 and Member Bill of Rights are reviewed and the Comprehensive Assessment is updated with the member, annually (as evidenced on the Annual Acknowledgement form).

Interpretive Guidance:
1. Signatures should be present on all Acknowledgement Forms (Typed or Electronically Signed are acceptable).2. Policy C3: The Member Acknowledgement Form must be signed by the Member when the opportunity arises to review the Plan with the Member.

COVID Temporary Guidance:
April 1, 2020: Documentation of updates done via phone without signed form is acceptable (with COVID reason)If done in -person, expect to see form signedCOVID: Give credit for documentation of events done, even if no form (with COVID reason)

Blue Example:
If all three had been reviewed: 5055, Bill of Rights, Comprehensive Assessment AND there is an uploaded acknowledgement form dated within the audit period that reflects these items as checked off.

Yellow Example:
If Comprehensive Assessment was reviewed but the 5055 and BOR was not.

Red Example:
If activities were completed F2F but no Acknowledgement Form.


Question:
Initial Comprehensive assessment is done within 30 days of enrollment.

Red Example:
Was completed late without a clear reason or there was no evidence of completion.


Question:
Annual Reassessment: Comprehensive assessment is done annually. If not completed in on time, documentation clearly shows reason for delay and efforts made to coordinate with member.

Blue Example:
Was completed on time or documentation was present explaining why it was completed late


Question:
Annual comprehensive assessments are completed appropriately (in person with the Member and reflect current needs / updates).


Question:
The SDOH Assessment is done with the member, annually. (As of 2023.)

Interpretive Guidance:
Should be done with all Plans of Care, including the first one done within 60 days.Leave a comment if SDOH is not aligned with the Plan (especially if it is completed after the Plan)- note trend in write up if needed.

Blue Example:
Completed every six months (year starting January 1, 2023) with the Plan of Care

Yellow Example:
One of the two SDOH assessments completed within the year was completed lateThis will need to be modified post- 1/1/2023


Question:
CAGE-AID completed on all members at the time of the initial comp assessment.

Red Example:
Was completed late without a clear reason or there was no evidence of completion. "Late" being after the POC was developed


Question:
The plan of care is completed within 30 days of completion of the initial assessment OR within 60 days of enrollment.

Interpretive Guidance:
** This refers to the 1st full plan of care. Not our placeholder one.


Question:
The plan of care is reviewed at least annually, using the Annual plan type in CareManager. (As of 2023.)

Interpretive Guidance:
1. Starting in 2023, Plans should be updated annually to bill.  Telephonic updates (with a COVID reason) are acceptable until NYS DOH says otherwise.2. We are looking for Biannual updates up until 1/1/2023. 3. For 2023 audits, be sure to double check billing with an outdated Plan of Care.4. Policy C3 Section C: Billing for Core Service delivery may not occur if the Member’s Plan of Care is not up to date by the end of the billing month (without a documented COVID reason)

COVID Temporary Guidance:
1. April 1, 2020: Plan of Care updates waived2. If update is done, give credit3. If not done, N/A4. If CC is in contact with Member and not updating Plans, do not score negative, but note trends in write up as caution

Blue Example:
If the Plan was updated within the audit year.

Red Example:
If the Plan was not updated within the audit year.


Question:
The plan of care is completed face to face.

Yellow Example:
If only one Plan was completed telephonically with a COVID reason and the other was telephonic without a COVID reason.

Red Example:
The POC was completed telephonically without a COVID reason.


Question:
At the time of POC review, is there a signed acknowledgment form to evidence member participation in the plan update (or clear documentation as to why the member could not participate, such as an update when in DSE).

Interpretive Guidance:
Signatures should be present on all Acknowledgement Forms (Typed or Electronically Signed are acceptable).Policy C3: The Member Acknowledgement Form must be signed by the Member when the opportunity arises to review the Plan with the Member.POC update switched to Annual after 1/1/2023.

COVID Temporary Guidance:
If Plan of Care was completed due to a true COVID-19 related reason (Member was ill or Member was uncomfortable with CC meeting in person) it is okay to complete telephonically and not expect to see Acknowledgement Form. This information should be documented in the notes.

Blue Example:
Plan of Care was completed face-to-face and form is present.

Yellow Example:
1. If only one POC was documented in the notes AND there is no presence of acknowledgement form (leave comment if necessary). 2. If only one acknowledgement form is uploaded, but both Plans have been completed F2F. 3. If only one Acknowledgement form is uploaded (one F2F) and the other is documented in the notes as done telephonically without a COVID reason.*After Annual updates are in effect, a yellow score is no longer applicable (see red scoring).

Red Example:
1. No acknowledgement form uploaded, regardless of if it was done with the Member.2. If the CC had completed the POC telephonically without a COVID reason.


Question:
If the POC was updated without the member present (such as when the member is in DSE), then are efforts made to engage the member in updating the POC once the member is reconnected with service. (POC is updated and acknowledgment form signed.)

Interpretive Guidance:
Policy C3 Section C: Should attempts to update the Plan of Care with the Member be unsuccessful, CMA’s do have the option to update the Plan without the Member present so that billing can occur. In these rare circumstances, the Plan must be reviewed with the Member at the next opportunity. In instances in which a Plan is updated without the Member present, the Care Notes should reflect this situation.

Blue Example:
1. If there were efforts documented to engage the Member in updating the POC that were unsuccessful2. If the Plan was updated without the Member present (i.e. disengaged, unable to contact) AND there was a documented reason to describe the situation AND the POC was reviewed at the next opportunity.

Red Example:
If there were no efforts documented to engage the Member in updating the POC and it was updated without Member participation

N/A Example:
Member was never placed in DSE OR Plans were never updated without the Member present OR the Member was never reconnected to services while in DSE.Important to note that this is not just for DSE cases, but anytime a Member is not available to update a POC or it is not an appropritate time to update it (in crisis, for example)


Question:
Member strengths and barriers to care are identified on the plan of care. (This should match or relate to the strengths/barriers from the comp assessment or more recent ones that the member has identified and are documented in the notes.)

Interpretive Guidance:
Make sure that barriers are addressed as an objective or intervention on the Plan.

Blue Example:
If strengths and barriers are identified on the Plan and are relevant to the Member based on Comp and notes

Yellow Example:
If one of the two are present (strengths/barriers)

Red Example:
If strengths and barriers are not identified.


Question:
Is there evidence that the care plan is being updated for significant events and as needs change? (i.e. If new issues or goals arise, goals met, or discontinued are those changes being reflected in the plan of care?)

Interpretive Guidance:
Use your judgement between green and yellow scoring.

Blue Example:
Evidence Plans are being amended in real-time and/or Interventions are marked as completed after goal was attained.

Green Example:
If Plans are updated with changes but not in real-time (waits until biannual to update)

Yellow Example:
If Plans are updated with changes but not in real-time (waits until biannual to update)

Red Example:
Significant changes occur and Plan is not updated.


Question:
Interventions are clear, concrete, achievable activities for the member. Interventions can be maintenance, such as 'continue to ___' but should also have small achievable steps when applicable.

Blue Example:
Good mix of some maintenance and smaller achieveable Interventions

Red Example:
All maintenance interventions ('cookie cutter')


Question:
The plan of care timeframes are realistic; not all set to same date range such as 6 months out. Six month timeframes are acceptable for ongoing maintenance interventions.

Interpretive Guidance:
Keep an eye out for target dates set to six months out and then carried over from Plan to Plan.

Blue Example:
Good mix of shorter timeframes for smaller achieveable Interventions and okay if some maintenance Interventions are set to six months out.

Red Example:
All timeframes are set to six months out despite some Interventions being attainable prior to six months.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.) The Plan of Care contains a Physical or Behavioral Health Objective.

Red Example:
1. Completion of the POC was not documented in the notes.2. If there was a separate issue that is not pertenant to the above questions, score red and/or leave a comment. *Bring to huddle or supervision if uncertain of reason for scoring red.


Question:
The plan of care addresses all identified needs unless clearly documented as resolved. (needs from assessments, referral, notes, etc.)


Question:
.--- Need for ANY OTHER IDENTIFIED SERVICES if identified as a need are addressed in the care plan. (Objective/Interventions/Timeframes)

Blue Example:
If the need was identified on an assessment AND the need is identified on the POC.

Green Example:
If the need was addressed on the Plan, but doesn't move the Member towards the overall Objective (use your judgement between green or yellow scoring)

Yellow Example:
If the need was addressed on the Plan, but doesn't move the Member towards the overall objective (use your judgement between green and yellow scoring)

Red Example:
If the need was identified on an assessment, in notes, or problems tab AND the need was not be identified on the POC.

N/A Example:
1. If there was no need identified and not included on the POC. 2. If a need was included on the POC, but wasn't identified as a need in the assessments, notes, or problems tab.


Question:
A minimum of one monthly core service for the member is documented. If not, then there is documentation of why no core service was provided. (member out of area, refusal by member, etc.)

Interpretive Guidance:
For these questions, how can we take into account staffing issues?  RSS does a "coverage caseload" and we saw with ACDMH that when downstaffed, there simply just are not enough resources to cover all cases.

Yellow Example:
If one month does not have a core service AND there are no attempts made by the CC for the month.

Red Example:
If at least two months or more months did not have a core service and there was no adequate explanation as to why (i.e. COVID-related reason).


Question:
HML billing assessment correctly reflects billable services rendered.

Interpretive Guidance:
Billing for Core Service delivery may not occur if the Member’s Plan of Care is not up to date by the end of the billing month (without a documented COVID reason)

Blue Example:
If all billing assessments were completed to correctly reflect a billable service.

Red Example:
If there was at least one billing issue.*Including POC not being updated.


Question:
On the member's current (most recent HML), for questions 3 through 8 was supporting documentation present when needed. (uploaded into the member's chart.)

Interpretive Guidance:
Does this question pertain to the last month of the audit year? (For example, with Bethesda, do we look at December 2022 HML's?)If question 8 is answered positively we may need to bring this to huddle/supervision to determine if it should be based on the factors listed in policy. - If Q8 is a Yes, we need documentation of a severe disease state in terms of the addiction diagnosis.Pay attention to whether questions 3-8 were answered CORRECTLY by reading note documentation (if a Member was inpatient within the audit year, then the corresponding question should reflect that).

Blue Example:
If any of questions 3-8 were correctly answered 'yes' or correctly answered 'no' AND there is supporting documentation uploaded (if needed) within the correct timeframe. *Correct timeframes are included on the question itself (Incarceration documentation is required within one year).

Green Example:
If HML question(s) should be answered as 'yes' but are answered as 'no'.Leave a comment with details of what needs to be uploaded/updated on the HML.

Yellow Example:
HML accurately reflects a 'yes' BUT there is not uploaded supporting documentation.

Red Example:
If the HML inaccurately reflects a yes AND there is no supporting documentation.


Question:
If member identified cultural preferences that they wanted addressed or acted on, those cultural preferences identified are addressed and acted upon as needed? (As evidenced in notes.)

Blue Example:
If the Member had cultural preferences and the CC actively worked to keep those preferences while working on care activities (For example if the CC did their due diligence to connect the Member with translation services).

Red Example:
If the member had cultural preferences and the CC ignored these preferences.


Question:
Care is member-centered. Activities are centered on member needs. (Activities reflect the goals and objectives in the care management plan.)


Question:
.--- If a member identified family/caregiver involvement, have member preferences been acted upon? (E.g. member wants updates to mother, is there evidence in the chart to support the mother receiving updates?)

Interpretive Guidance:
Family Member must be included in the 5055 or a separate ROI.

Blue Example:
If the Member had identified a family member/caregiver to be involved in their care and the CC actively took steps to involve them.

Red Example:
If the Member had identified a family member/caregiver to be involved in their care and the CC DID NOT include them.


Question:
.--- If member was able to begin managing self care, did the care coordination promote member independence. (i.e. CC teaches the member how to set up MAS vs making all MAS calls.) (Activities are proactive and promote empowerment.)

Interpretive Guidance:
1. Use your best judgement when it comes to MAS--some Members experience difficulties with scheduling transportation through MAS. 2. Ask yourself "was the Member capable of scheduling their own appointments?"

Blue Example:
1. If the Member had demonstrated independence and the CC actively took steps to improve/maintain their independence/ readiness. 2. The Member shows that they are capable of starting to manage their care independently and the CC is actively encouraging/ working towards independence/ readiness.

Yellow Example:
If some evidence of attempts were made--use your judgement between yellow and red scoring.

Red Example:
If the Member had demonstrated independence/ readiness, but the CC continued to schedule appointments and services on their behalf.

N/A Example:
If the Member is not in a current state in which they can demonstrate independence and still requires assistance from the CC.


Question:
.--- Documentation reflects that care management team advocated for services and assisted with scheduling of needed services. Did the Care Coordinator follow-up on missed appointments and problem solve with member on making future appointments?

Interpretive Guidance:
If the CC had taken into account the Member needs and appropriately followed up on those needs--see control #96.

Blue Example:
If the CC had made attempts to advocate on the Member's behalf if warranted.

Yellow Example:
If the CC had advocated for the Member to receive needed services, but they did not follow through or assist with getting the Member these services.

Red Example:
If the CC did not make an effort to advocate for the Member when they were in need of services.


Question:
.--- Barriers identified in the plan of care are addressed and acted upon as needed (as evident in notes).

Interpretive Guidance:
Barriers should also be addressed on the Plan in order to guide care activities.

Blue Example:
If barriers on the POC were clearly problematic in note documentation and were addressed appropriately.

Yellow Example:
If multiple barriers (2+) were present and only one was worked on (although the other was just as relevant).

Red Example:
If barriers were present, were not included in the POC, and not addressed in note documentation when needed.

N/A Example:
1. We would likely look for barriers to be updated on POC if no longer problematic. 2. If there are no barriers listed on the POC (separate issue).


Question:
.--- Over the past year, is there evidence that the CC is addressing all objectives from the plan of care with the member. If not, is there evidence that the CC has reasonably attempted to address objectives?

Blue Example:
If the CC had actively worked on (or at least attempted) addressing ALL of the objectives on the POC.

Green Example:
If the CC had actively worked on (or at least attempted) addressing MOST of the objectives on the POC.

Yellow Example:
If the CC had actively worked on (or at least attempted) addressing less than half of the objectives on the POC.

Red Example:
If the CC did not actively work towards completing POC objectives.


Question:
.--- Follow up on member issues are evident. (i.e. If member asked for assistance, did the care coordinator offer assistance and follow up to ensure needs were met.)

Interpretive Guidance:
Sufficient time for follow up is defined by the acuity of the case and the prioritization of the need(s).  (Every situation is different--use your judgement with scoring).

Blue Example:
If the Member had asked for assistance regarding an issue and the CC had attempted or actively worked to address the issue.

Green Example:
If the CC had attempted or actively worked to address MOST of their issues, if asked by the Member.

Yellow Example:
If the CC had attempted or actively worked to address less than half of their issues, if asked by the Member.

Red Example:
The CC did not attempt nor actively work to address issues that the Member had asked assistance for.


Question:
.--- If the notes indicate next steps for the Care Coordinator, then those next steps are documented. If the CC stated they would make a call or meeting was there documentation that those contacts took place (or documentation why they did not).

Blue Example:
If the CC had stated they would follow up on Member needs and did so.

Green Example:
If the CC had stated they would follow up on Member needs and followed up on most of those needs.

Yellow Example:
If the CC had stated they would follow up on Member needs and followed up on less than half of those needs.

Red Example:
If the CC had stated they would follow up on Member needs and did not follow up on those needs.


Question:
.--- Frequency of contact with the member was appropriate based on member needs. (i.e. If member had immediate complex needs such as an eviction did the care coordinator make additional contacts to ensure members needs were met.)

Blue Example:
If CC met the minimum contact requirements or more based on Member needs/acuity

Green Example:
Use your judgement between green and yellow scoring.

Yellow Example:
Use your judgement between green and yellow scoring.

Red Example:
If the Member displayed a need for increased support/contact, did the CC reciprocate efforts/increase contact.


Question:
.--- If member went into crisis, documentation reflects crisis intervention activities. (Medical or Behavioral Health.)

Interpretive Guidance:
This applies to SOME AOT pick-up orders---Use your discretion.

Blue Example:
If the CC had documented crisis intervention activities after a major medical or behavioral health crisis/episode.

Red Example:
The Member was in crisis did the CC did not respond appropriately (medical/psychiatric)


Question:
.--- Based on individual needs and preferences, The care coordinator promotes wellness and prevention by linking the member with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services.

Blue Example:
If the CC had provided resources to the Member that could aide-in prevention efforts/risk reduction for their chronic condition(s), when warranted.

Green Example:
If the Member was interested in resources but CC only addressed some of these needs (ex: AA meetings and smoking cessation, only one of those two needs were met).-- use your judgement between green and yellow scoring

Yellow Example:
If the Member was interested in resources but CC only addressed some of these needs (ex: AA meetings and smoking cessation, only one of those two needs were met). -- use your judgement between green and yellow scoring

Red Example:
If the CC had NOT provided resources to the Member that could aide-in prevention efforts/risk reduction for their chronic condition(s), when warranted.


Question:
Was the MCO notified when the Member experienced barriers to service or when the Member experienced a significant event or change in status that would impact Member care (i.e., suicide attempt, housing disruption, step on or off HH+ services, etc.)?

Interpretive Guidance:
1. Contacting the MCO to notify them of the Member receiving HH+ services or being stepped down from HH+ services is scored under the HH+ domain and is therefore not applicable in scoring this question. 2. Contacting the MCO to notify them of a status change (during DSE) is scored under the DSE domain and is therefore not applicable in scoring this question.

Blue Example:
If contacting the MCO was warrented AND the CC actively worked towards collaborating with the MCO/HARP CM

Yellow Example:
If the CC contacted the MCO to notify them of a Member need, but did not actively work towards collaborating with the MCO/HARP CM thereafter

Red Example:
If the Member could have benefitted from assistance from the MCO, but there was no evidence of collaboration.

N/A Example:
1. If questions regarding the MCO being contacted are scored under other relevant questions AND there was no other MCO collaboration that was warrented. 2. The Member does not have an MCO.


Question:
Notes contain evidence of attempts to collaborate care with member's treatment team when appropriate. (i.e. If member reports feelings of suicidality  was the mental health provider notified.)

Interpretive Guidance:
If collaboration was not present- ask ourselves was collaboration warranted and did not occur or is the Member managing most needs independently and nearing graduation.

Blue Example:
If collaboration with the Members' care team was warrented (see interpretive guidance) AND there was evidence of collaboration with the care team from the CC.

Green Example:
If there was some collaboration with the care team from the CC, when warrented. (Use your judgement between green and yellow scoring.)

Yellow Example:
If there was some collaboration with the care team from the CC, when warrented. (Use your judgement between green and yellow scoring.)

Red Example:
If collaboration with the Members' care team was warrented AND there was NO evidence of collaboration with the care team from the CC.

N/A Example:
If questions regarding care team collaboration was scored under other relevant questions (HH+ and AOT) AND if collaboration with care team Members was not warrented


Question:
If 60 days passed with no contact with the member, were they placed in diligent search? If the member was placed in diligent search prior to 60 days, were there at least 30 days with no contact despite meaningful attempts to contact?

Interpretive Guidance:
This question does not apply to Members who are incarcerated or in an excluded setting (extended) hospitalization.*Policy changed 3/1/2023 to reflect timing of DSE activites on a month to month basis.

Blue Example:
Members were placed into DSE appropriately

Red Example:
Members were placed into DSE inappropariately OR needed to be placed into DSE status but were not.


Question:
Was the Member's MCO notified of the status change, if applicable, during the first month of DSE?

Interpretive Guidance:
Best practice: Confirm MCO in ePaces because Eligibility Tab in CareManager is not always accurate. Please think about how quickly Members moved in and out of DSE status before scoring negatively.

Blue Example:
MCO was notified during the first month of DSE

Green Example:
MCO was notified but not in month one of DSE

Red Example:
MCO was not notified regarding DSE status.


Question:
Was the POC updated to reflect Diligent search activities that were relevant to the member?

Interpretive Guidance:
Please think about how quickly Members moved in and out of DSE status before scoring negatively.

Blue Example:
POC was updated to reflect DSE activities

Red Example:
POC was not updated to reflect DSE activities


Question:
Did the number of diligent search activities meet the minimum requirement to bill? (At least 3 different efforts.)

Interpretive Guidance:
If three different efforts were performed AND met the criteria to bill, but did not, add the chart and billing comment in the Auditors Notes billing table. *Do not score negatively.

Blue Example:
1. Three different efforts were performed to meeting criteria to bill.2. If there were less than three DSE activities, but the Member had been contacted and re-engaged in services before three could be met.

Yellow Example:
If at least one month contained three different attempts.

Red Example:
1. Three different efforts were not performed AND the month was billed. *Add to billing table in Auditors Notes2. Three different efforts were not performed


Question:
Were diligent search activities meaningful, progressive, and diverse?

Blue Example:
CC took meaningful and diverse steps to reach the Member as outlined in policy and on the Plan of Care.

Green Example:
Use your judgement between green and yellow scoring

Yellow Example:
Use your judgement between green and yellow scoring

Red Example:
CC attempted to reach the Member by the same mode of unsuccessful contact (i.e. calls/texts to a non-working number)AND/OR did not exhaust all interventions on the POC


Question:
If the Member was located while in DSE, did a conversation occur to attempt to re-engage the Member in Health Home Services?

Blue Example:
CC successfully re-engaged the Member and problem solved for what led up to the Members disengagement

Red Example:
Member re-engaged with services but what led up to the Members disengagement was not discussed.

N/A Example:
The Member had not been successfully located while in DSE.


Question:
Care Coordinator responded to alerts of hospitalizations and ED visits – and any other events calling for the provision of Care Transition services within 2 business days of receiving the alert.

Blue Example:
The CC responded to all Hixny alerts within 2 business days after receiving the alert.

Green Example:
The CC responded to most of the Hixny alerts within 2 business days.

Yellow Example:
Use judgement between yellow and red scoring.

Red Example:
The CC responded to less than half of the Hixny alerts within 2 business days.


Question:
If reason for the visit could have been handled by primary care or urgent care, was the member given education regarding appropriate use of the emergency room.

Interpretive Guidance:
Definition of when warranted:If Members went to the ED for a condition that could have been treated by PCP or urgent care (such as a hang nail, headache, stomach ache, etc). We would expect  to see the CC providing options prior to going to the ED (if possible) but definitely reviewing their inappropriate ED use afterwards. If ED visit was a true emergency (such as exibiting signs of a heart attack, car accident, etc), anything that appears to be a true emergency and/or potentially life threatening. We want to see Members access emergency services.

Blue Example:
If the CC had educated the Member on the proper uses of urgent care versus the ED, either before or after a Hixny event, when warranted.

Red Example:
If the CC had not educated the Member on the proper uses of urgent care versus the ED, neither before nor after a Hixny event, when warranted.

N/A Example:
If the Member truly needed to access emergency services.


Question:
If the ER/Hospitalization resulted in the need for new providers or significant change in needs, was the POC updated. (For example, a member who needs post-operative care following heart surgery should have this on the POC.)

Blue Example:
If the Member had a significant event that resulted in the need of new treatment and the POC was updated to reflect this. Use your judgement between Blue and Green socring.

Green Example:
If the Member had a significant event that resulted in the need of new treatment and the POC was updated to reflect this. Use your judgement between Blue and Green socring.

Yellow Example:
If the Member had a significant event that resulted in the need of new treatment and the POC was updated, but the CC waited until an annual update to add it to the Plan.

Red Example:
If the Member had a significant event that resulted in the need of new treatment and the POC was NOT updated to reflect this.


Question:
Care coordinator assists member in following their discharge plan when transitioning back to the community.

Blue Example:
If all of the rollup questions are blue.


Question:
.--- Discharge instructions from ER visits and hospitalizations are obtained and used to help member transition back to the community; appointments kept, meds obtained, etc. If not, does documentation show an attempt to obtain the discharge plan.

Blue Example:
If the CC made an attempt at reviewing discharge instructions with the Member AND uploaded the summary into CareManager.

Green Example:
If the CC made an attempt at reviewing the discharge instructions with the Member, but did not uploaded the summary into CareManager.

Yellow Example:
If the CC uploaded the discharge summary into CareManager, but did not attempt to go over the summary to determine next steps.

Red Example:
If the discharge summary was not reviewed, nor was it uploaded into CareManager.


Question:
.--- Documentation shows that the care coordinator notified/collaborated with the care team upon notification of member’s transition to/from an ER/hospital/residential/rehabilitative setting (Providers/MCO).

Blue Example:
If the CC had notified appropriate members of the care team after a hospital visit, when warrented (minor ailments such as hang nail, stomach ache do not need to be promulgated unless there is a pattern--use your judgement).

Green Example:
If the CC had notified some Members of the care team after a hospital visit, but did not update all relevant providers. Use your judgement between Green and Yellow scoring.

Yellow Example:
If the CC had notified some Members of the care team after a hospital visit, but did not update all relevant providers. Use your judgement between Green and Yellow scoring.

Red Example:
If the CC had NOT notified appropriate members of the care team after a hospital visits, when warrented.


Question:
.--- If member has social supports, support resources and persons were identified with member to assist in the time of crisis and aide in preventing future crisis.

Interpretive Guidance:
Social supports in this instance are defined as consented contacts that have demonstrated an active role in the Member's care.Support resources such as suicide prevention hotline, AA/NA, emergency contact phone numbers, safety plan, etc.

Blue Example:
If the Member had social supports/resources, they were notified of the incident, and there was a discussion surrounding prevention efforts for future crises.

Yellow Example:
If the Member had social supports/resources and they notified of an incident, BUT there was NO discussion regarding prevention of future crises.

Red Example:
If the Member had social supports/resources and they were not notified of an incident.

N/A Example:
If the Member had no participating social supports/resources that would be necessary to notify in the event of a crisis.


Question:
.--- If member transitioned between criminal justice or any inpatient setting, was a warm handoff facilitated or an attempt to facilitate was documented. For inpatient stays, did the Care Coordinator attemped to collaborate with staff?

Blue Example:
If the CC had attempted to discuss discharge/transition efforts with healthcare staff (nurses, social workers, etc.) prior to the Member's discharge/transition from one setting to another.

Green Example:
Use your judgement between blue and green scoring.

Yellow Example:
CC made an initial attempt to contact hospital staff but did not make any further attempts to ensure discharge/transition efforts with healthcare staff prior to discharge.

Red Example:
CC had an opportunity to discuss discharge/transition efforts with healthcare staff prior to discharge but did not attempt to do so.


Question:
Case Conferences and Team Meetings are held when appropriate (per policy guidance).

Interpretive Guidance:
Credit should be given for AOT case reviews/renewal meetings.Policy I2 Section A: A Case Conference may be appropriate when a Member:-Has recently been or is frequently hospitalized-Frequently visits the Emergency Department-Displays a pattern of behaviors which result in concerns for the safety of the Member or others around the Member or experiences another critical event-Requests a Case Conference be held on their behalf-Is undergoing treatment which may be conflictual in nature (i.e., medications or treatments are interacting negatively with one another or are preventing the Member from making progress towards overall well-being)-New providers are added to the Member’s care teamIn CareManager, Case Conferences should be documented as a CareManager Note with “Multidisciplinary Team” selected as the Target in the Pariticipants section of the note.

Blue Example:
1. If a Case Conference was warrented and was conducted for each occurance it was necessary 2. If a case conference was warranted but could not be facilitated, the Care Coordinator made attempts to collaborate with relevant providers/close the loop.

Yellow Example:
If a Case Conference was warranted and there was an attempt to facilitate one, but was not conducted AND the CC did not try any other solutions.

Red Example:
If a Case Conference was warranted and was NOT conducted nor was there an attempt.


Question:
Care coordinator works with member to address barriers and root cause for repeat ER/IP utilization. (Such as connecting with outpatient care, meeting SDOH needs.)

Blue Example:
If the Member experiences an influx of ED visits, then the CC at least attempted to solve for barriers and root cause in order to reduce hospital utilization.

Red Example:
If the CC did not attempt to solve for barriers in persuit of reducing uneccesary ED visits.


Question:
Was there ongoing case collaboration with care team members (outside of formal case conferencing) to help address member needs and reduce utilization?

Blue Example:
If the CC had collaborated with members of the care team following frequent ED visits AND discussed reduction methods.

Red Example:
If there was no collaboration with the care team to attempt to reduce ED visits.


Question:
Is the member's high utilization addressed on the Plan of Care?

Blue Example:
If there was an objective with appropriate interventions that addressed high utilization.

Red Example:
If there was no evidence of addressing the Member's high utilization on the POC.


Question:
Was the member assigned to the HH+ program type in Care Manager?

Blue Example:
Member assigned to HH+ program type appropriately (according to the HH+ eligbility checklist).

Red Example:
Member not assigned to correct program type or no program type


Question:
Does the member have clear evidence of HH+ eligibility? (Current Eligibility form and Medical Records showing evidence are in the uploaded documents.)

Blue Example:
Member has eligibility form and supporting records uploaded.

Green Example:
Medical records are present but HH+ eligibility form is not uploaded (2023 audit period)

Yellow Example:
Medical records are present but HH+ eligibility form is not uploaded (2022 audit period)

Red Example:
Member does not have evidence of eligbility uploaded *Immediate report out


Question:
For HIV HH+, at 6 months, a review of the POC and HIV assessment took place F2F at the members home. This included an eval of viral load and progress towards the objectives. This re-assessment of progress and status is written as a CM Note.

COVID Temporary Guidance:
If they conducted the HIV assessment over the phone, there needs to be a COVID-related reason.

Blue Example:
Both tasks were completed appropriately OR documented attempts to complete in the home but Member refused

Red Example:
POC review and HIV assessment not completed


Question:
For HIV HH+, at six months a case conference took place with consented providers.

Interpretive Guidance:
At a minimum, the HIV provider should be in attendance.

Blue Example:
Completed appropriately OR attempts to complete - maybe attempted to schedule, but could not get people?


Question:
Did documentation in chart reflect a need for HH+ services? (Member meets acuity and appropriatness criteria for the HH+ program.)

Interpretive Guidance:
1. Use your judgement if the Member is not well engaged with HH+ services and there isn't evidence to support a need for a minimum of 4 core services a month.

Blue Example:
Plan and notes reflect a need for services

Yellow Example:
Plan does not reflect a need for HH+ services OR notes do not reflect a need for HH+ services (one out of the two).


Question:
Did the plan of care include objectives related to the reason the member qualifed for HH+ services?

Blue Example:
Plan includes reason (diagnoses) and qualifying criteria (high hosp. utilization, homelessness, etc)

Yellow Example:
Plan does not include reason OR does not include qualifying criteria (includes one out of the two)


Question:
Were the minimum core service delivery requirements met? (Member received at least 2 F2F core services and 2 other core services in the month.) If not, were actions taken to attempt to deliver core services.

COVID Temporary Guidance:
April 1, 2020: Face to Face contact requirement waived (with documented COVID reason)

Blue Example:
Minimum core service delievery requirements were met OR documentation shows a reason as to why they were not.

Green Example:
If there was at least one instance of minimum core service delivery requirements were not met, without a clear reason.

Yellow Example:
If there was at least two instances of minimum core service delivery requirements were not met, without a clear reason.

Red Example:
If three or more instances of minimum core service delivery requirements were not met, without a clear reason.


Question:
Was the contact type and amount of contact appropriate based on member acuity. (For example, if member had acute needs that required more than two F2F core services, were core services delivered to ensure needs were met.)

Blue Example:
Member received proper amount of contacts based on acuity (minimum core service delievery requirements or more contact if needed)

Green Example:
Use judgement between green/yellow scoring

Yellow Example:
Use judgement between green/yellow scoring

Red Example:
Member required more contact (in addition to the contacts made in order to be able to bill) but did not receive the level of support needed.


Question:
The HH+ rate was only billed when appropriate.

Interpretive Guidance:
*Leave a comment if the month could have been billed at the HH+ rate but was not. Do not ding.

Red Example:
Billed at the HH+ rate but did not meet minimum requirements to do so *Add to billing table


Question:
Does the HH+ qualifying category on the HML match documented eligibility criteria?

Interpretive Guidance:
If the HH+ qualifying criteria on form was for homelessness, but the HML checked off criminal justice involvement that was also supported by documentation, then it would be acceptable to score blue (should be noted in comments though)

Blue Example:
HML HH+ criteria matches the HH+ eligibility form criteria (also see interpretive guidance comment).

Red Example:
HML HH+ criteria does not match HH+ eligiblity form criteria AND criteria documented under the HML is not applicable (unlike what is outlined under the interpretive guidance)

N/A Example:
N/A if the Member does not have a HH+ eligibility assessment uploaded (cannot verify actual eligbility criteria without it).


Question:
A copy of the most recent and active AOT order is scanned into the documents of the chart.

Blue Example:
Active AOT order is uploaded to the chart

Red Example:
Active AOT order is not uploaded to the chart*If active AOT order is not uploaded, this would be an immediate report out


Question:
The AOT member is identified as such in the Programs section of CareManager.

Blue Example:
AOT program type is identified in CareManager

Red Example:
AOT program type is not identified in CareManager


Question:
The Plan of Care includes all categories of service listed in the court-ordered AOT treatment plan.

Blue Example:
All criterion listed on AOT order is included on Plan

Green Example:
Plan is missing one criterion listed on AOT order.If the Plan generally covers outlined criteria on AOT order

Yellow Example:
Plan is missing two or more criterion listed on AOT orderIf the Plan leaves out specific/time sensitive details (i.e. monthly IM injection, meeting with OP MH tx provider weekly)

Red Example:
Plan does not reflect criterion listed on AOT order


Question:
The AOT member received 4 face to face core services per month (with documentation if unable to achieve).

Interpretive Guidance:
Check the AOT Final Order if it specified 'weekly contact' under the categories of service. If these conditions were not met, score under 'other issues.'

Yellow Example:
If at least ONE month did not meet the 4 F2F requirements (without any documented reason as to why)

Red Example:
If two or more months did not meet the 4 F2F requirements (without any documented reason as to why)


Question:
If the AOT member was considered missing (no credibly reported contact within 24 hours of the Care Coordinator receiving notice that the person had an unexplained absence from an apt), were appropriate steps taken to seek out the member?

Interpretive Guidance:
See policy F2 section H to determine scoring

Blue Example:
See policy F2 section H to determine scoring

Green Example:
See policy F2 section H to determine scoring

Yellow Example:
See policy F2 section H to determine scoring

Red Example:
See policy F2 section H to determine scoring


Question:
If the AOT member was considered missing (per above), was a missing persons report filed with the police within 24-48 hours?

Interpretive Guidance:
Review incident reporting log to verify this was reported to CRHC. W:\CRHC HH Admin\Incident Reporting

Blue Example:
Missing persons report was filed with the police within 24-48 hours

Red Example:
Missing persons report was not filed with the police within 24-48 hours


Question:
Was there evidence of collaboration with providers identified in AOT Tx Plan, especially around non compliance with AOT Treatment Plan services?

Blue Example:
Ongoing contact is made with clinical team to verify compliance and connect about Members

Green Example:
Use judgement between blue and green scoring based on definition listed under blue example.

Yellow Example:
Opportunities were missed to collaborate at times but there were some examples of attempts to collborate

Red Example:
No attempts to meaningfully collborate with providers and/or only received Member report-outs of AOT compliance


Red Example:
1. If AOT order requires weekly contact, but this was not done  *Leave comment2. If there was a separate issue that is not pertenant to the above questions, score red and/or leave a comment. *Bring to huddle or supervision if uncertain of reason for scoring red.


Question:
The HARP Program type is correctly identified in the chart.

Blue Example:
If the HARP program type correctly reflects their assigned code in ePACES.

Yellow Example:
If both HARP Eligible and HARP Enrolled program types are listed as active *Leave a comment

Red Example:
If the HARP program type does not correctly reflect their assigned code in ePACES.


Question:
Staff perform HARP eligibility assessment or core referral at least annually or when there is a significant change in status for HARP (or notes indicate HARP services were declined).

Interpretive Guidance:
1. HARP activity - F2F requirement permanently lifted

Blue Example:
If the HARP eligibilty assessment was done annually.

Green Example:
If the HARP eligibilty assessment was completed 1-2 months late.

Red Example:
If the HARP eligibilty assessment was not done annually, with no explanation as to why (i.e. Member refusal).


Question:
If the eligibility assessment was completed and the member was interested in service, was there evidence that the LOSDR (service determination request/ the Preliminary Plan of Care) was sent to the MCO. (Uploaded request to documents.)

Blue Example:
If the LOSDR was sent to the MCO when warranted.

Yellow Example:
If note documentation indicates the LOSDR was submitted but it was not uploaded to the chart.

Red Example:
If the LOSDR was not sent to the MCO when warranted.


Question:
If notes indicated a LOSD response was received from the MCO, a copy of the MCO response is in the documents.

Blue Example:
If there was an LOSD response and that response was uploaded into CareManager.

Red Example:
If there was an LOSD response and that response was not uploaded into CareManager.


Question:
If member has an LOSD from the MCO, Is there documentation that steps were made to link the member to HCBS services.

Blue Example:
If there were documented steps taken to connect the Member to services.

Red Example:
If there were no documented steps taken to connect the Member to services.


Question:
If member has an LOSD from the MCO and is linked to services, then the full HARP POC is completed and a copy is attached in the documents.

Blue Example:
If the full HARP POC is completed and uploaded into CareManager.

Red Example:
If the full HARP POC is not completed nor uploaded into CareManager.


Question:
Was a CareManager 'General Assessment' done for each key HARP activity noting the HARP activity done. Each key HARP activity should have both a note documenting the encounter and a General Assessment.

Blue Example:
If there was a General Assessment done for each key HARP activity done.

Yellow Example:
If some activities were documented under the General Assessments tab, but not all (depending on how far along agencies are through the HARP process)

Red Example:
If there were no General Assessments recorded in CareManager, when warranted.


Question:
For all discharges, was the required discharge letter completed and sent to the member. If not, is there documentation of  why it could not be sent (i.e. no address).

Interpretive Guidance:
1. Still score for the presence of the DOH 5058 up until 5/1/2022. 2. After 5/1/2022, expect to see evidence of the completion of the discharge letter (through note documentation or discharge summary). If the discharge letter is not uploaded, do not ding but note as a trend in the OneNote and QMP write up.

Blue Example:
1. If the discharge letter was completed and sent to the Member, as evidenced in note documentation.2. If note documentation does not reference the discharge letter was completed but it was uploaded to the chart3. Note documentation / discharge summary gives a reason why the letter could not be sent

Red Example:
If the d/c letter was not referenced as sent anywhere.


Question:
If the member was discharged due to ineligibility, inappropriateness, or DSE, was the 5235 sent 10 days prior to closing. (Notice by means of Form DOH-5235 is required before the Health Home can disenroll.)

Interpretive Guidance:
This form is expected to be completed if the CMA initiates the discharge.

Blue Example:
If the 5235 was sent when required OR note documentation / discharge summary states why it could not be sent.

Red Example:
1. If the 5235 was not sent, when needed.

N/A Example:
1. If the DOH 5235 was sent, but the wrong code was used; If the correct code doesn't warrant use of the DOH 5235. 2. If the 5235 was sent and not needed (and leave a comment).


Question:
Does the reason for discharge selected reflect the reason for discharge in the discharge summary and notes.

Blue Example:
If the reason for discharge is consistant with the reason reflected in the discharge summary and notes.

Yellow Example:
If the reason for discharge was reflected in the notes, but not in the discharge summary (in the event of a missing discharge summary or not enough information).

Red Example:
If the reason for discharge is NOT consistant with the reason reflected in the discharge summary and notes.


Question:
For Members who were able to be contacted regarding the discharge, was the discharge discussed with the member prior to discharge to prepare member and ensure discharge readiness.

Blue Example:
If the discharge was discussed prior to discharge, if available.

Yellow Example:
If the discharge was discussed, but not with sufficient time to prepare the Member to ensure discharge readiness.

Red Example:
If the Member was in communication with the CC and the discharge was not discussed prior to discharge.

N/A Example:
If the Member was not able to be contacted regarding discharge.


Question:
A discharge summary was completed for the discharge. This discharge summary contains a detail of events leading up to the discharge.

Blue Example:
A discharge summary was uploaded into the Member's chart AND contatins details leading up to the discharge.

Yellow Example:
If a discharge summary was completed, but did not contain sufficient details leading up to the Member's discharge.

Red Example:
If a discharge summary was not completed.This includes auto auto discharges.


Question:
Was the summary shared or communicated to the care team members? (PCP, Mental Health Provider, Housing, MCO, etc.)

Interpretive Guidance:
1. This is not necessary in the case of a member death (Code 04). 2. Care team Members are only relevant if the Memeber had sufficient contact with them within the audit period. 3. The MCO should be notified at a minimum.

Blue Example:
If the summary was shared or communicatied to the care team Members (as evidenced by note documentation OR the discharge summary).

Yellow Example:
Discharge summary was shared with some providers but left out some relevant providers (such as the MCO)

Red Example:
The summary was not shared or communicated with the care team.

N/A Example:
If there were no providers active on the Member's care team.


Question:
If there were unmet needs and discharge was able to be discussed with the member, was there evidence of discharge plan from Health Home program including referrals to services or programs.

Interpretive Guidance:
A Member referred to another health home also counts.

Blue Example:
If the Member was available to discuss the discharge plan AND the CC had included referrals to additional services, if needed.

Red Example:
If the Member was available to discuss the discharge plan AND the CC did NOT include referrals to additional services, if needed.

N/A Example:
If the Member graduated from the program (theorectically, cases of graduation do not have unment needs, but in some cases they may) OR Member did not identify/want to address any unmet needs


# Master_Agency

Agency:
Catholic Charities Care Coordination Services


Agency:
Refugee and Immigrant Self Empowerment (RISE)


# Question_Matrix

Question:
Forms and Documents - Check in Attached Documents


Question:
Scanned documentation shows clear evidence of eligibility (contains documentation of a serious mental illness or HIV/AIDS or two of the following: mental health condition, substance abuse disorder, asthma, diabetes, heart disease, BMI > 25 or other).


Question:
If scanned records are present, do the diagnoses/problems captured in EMR match those in the member's records.


Question:
Member Information on demographics tab appears complete. (Language, Race, Gender, etc.)


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.)


Question:
Consent Form - Check in Attached Documents


Question:
Is the HIXNY consent entered correctly in CareManager. (Electronic HIE)? (Unless the member denies/withdraws consent.)


Question:
DOH-5055 Member Information Sharing Consent Form Completed Correctly (On the current/most recent 5055)?

References:
DOH: Instructions for Completing the Forms (DOH-5055, DOH-5058, DOH-5059)

Policy:
Policy B4. Outreach and Engagment: Health Home Con


Question:
Consent In Action - Determined when reading Notes


Question:
Updated copies of 5055 present when changes are made (changes in providers, supports, etc.).


Question:
The Member's PHI and confidentiality was kept. No coordination with entities or individuals outside of those named on the consent form is present in the EMR (i.e. there is no evidence of a PHI or confidentiality breach).


Question:
Engagement activities are clearly documented as being meaningful and progressive in nature. (More than one attempt, reasonable timeframes between attempts, evidence of alternative means of locating member, use of MCO, referent, and other resources.)


Question:
If the member was enrolled, is the DOH 5234 form completed and scanned in file. (Form DOH 5234 notifies the member of their Health Home enrollment. The notice should be mailed to the member along with the Health Home welcome letter.)


Question:
If the member was found to be ineligible prior to enrollment, is the DOH 5236 form completed and scanned in file. (It explains that they did not meet the criteria for enrollment and the reason for denial of enrollment.)


Question:
Signed copy of Bill of Rights scanned into EMR and completed correctly (from enrollment).


Question:
Completed intake assessment prior to or at the time of enrollment.


Question:
The Intake Assessment is completed appropriately and reflects current member needs. (Includes needs identified on the referral, in notes, or related to the members primary diagnosis, etc.)


Question:
The 5055 and Member Bill of Rights are reviewed and the Comprehensive Assessment is updated with the member, annually (as evidenced on the Annual Acknowledgement form).


Question:
Initial Comprehensive assessment is done within 30 days of enrollment.


Question:
Annual Reassessment: Comprehensive assessment is done annually. If not completed in on time, documentation clearly shows reason for delay and efforts made to coordinate with member.


Question:
Annual comprehensive assessments are completed appropriately (in person with the Member and reflect current needs / updates).


Question:
The SDOH Assessment is done with the member, annually. (As of 2023.)


Question:
CAGE-AID completed on all members at the time of the initial comp assessment.


Question:
The plan of care is completed within 30 days of completion of the initial assessment OR within 60 days of enrollment.


Question:
The plan of care is reviewed at least annually, using the Annual plan type in CareManager. (As of 2023.)


Question:
The plan of care is completed face to face.


Question:
At the time of POC review, is there a signed acknowledgment form to evidence member participation in the plan update (or clear documentation as to why the member could not participate, such as an update when in DSE).


Question:
If the POC was updated without the member present (such as when the member is in DSE), then are efforts made to engage the member in updating the POC once the member is reconnected with service. (POC is updated and acknowledgment form signed.)


Question:
Member strengths and barriers to care are identified on the plan of care. (This should match or relate to the strengths/barriers from the comp assessment or more recent ones that the member has identified and are documented in the notes.)


Question:
Is there evidence that the care plan is being updated for significant events and as needs change? (i.e. If new issues or goals arise, goals met, or discontinued are those changes being reflected in the plan of care?)


Question:
Interventions are clear, concrete, achievable activities for the member. Interventions can be maintenance, such as 'continue to ___' but should also have small achievable steps when applicable.


Question:
The plan of care timeframes are realistic; not all set to same date range such as 6 months out. Six month timeframes are acceptable for ongoing maintenance interventions.


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist. Please leave details of the issue in the comments section.) The Plan of Care contains a Physical or Behavioral Health Objective.


Question:
The plan of care addresses all identified needs unless clearly documented as resolved. (Needs from assessments, referral, notes, etc.)


Question:
.--- Need for primary care services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for home care services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for physical rehab services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for SUD services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for mental health services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for HIV/AIDS services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for housing is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for transportation is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for food is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Financial needs are addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for wellness and prevention services is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for specialty services (dental, podiatry, etc.) is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for advance directive information if identified as a need on the assessment. (Objective/Interventions/Timeframes)


Question:
.--- Objectives related to education (School) is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Objectives related to employment is addressed in the care plan. (if needed) (Objective/Interventions/Timeframes)


Question:
.--- Need for ANY OTHER IDENTIFIED SERVICES if identified as a need are addressed in the care plan. (Objective/Interventions/Timeframes)


Question:
A minimum of one monthly core service for the member is documented. If not, then there is documentation of why no core service was provided. (Member out of area, refusal by member, etc.)


Question:
HML billing assessment correctly reflects billable services rendered.


Question:
On the member's current (most recent HML), for questions 3 through 8 was supporting documentation present when needed. (Uploaded into the member's chart.)


Question:
If member identified cultural preferences that they wanted addressed or acted on, those cultural preferences identified are addressed and acted upon as needed? (As evidenced in notes.)


Question:
Other issues present? (Mark N/A if no additional issues are present, mark a red/negative response if issues exist.) (i.e. If member requested to change providers, when a referral to a provider is made, was the member is given choices?


Question:
Care is member-centered. Activities are centered on member needs. (Activities reflect the goals and objectives in the care management plan.)


Question:
.--- If a member identified family/caregiver involvement, have member preferences been acted upon? (E.g. member wants updates to mother, is there evidence in the chart to support the mother receiving updates?)


Question:
.--- If member was able to begin managing self care, did the care coordination promote member independence. (i.e. CC teaches the member how to set up MAS vs making all MAS calls.) (Activities are proactive and promote empowerment.)


Question:
.--- Documentation reflects that care management team advocated for services and assisted with scheduling of needed services. Did the Care Coordinator follow-up on missed appointments and problem solve with member on making future appointments?


Question:
.--- Barriers identified in the plan of care are addressed and acted upon as needed (as evident in notes).


Question:
.--- Over the past year, is there evidence that the CC is addressing all objectives from the plan of care with the member. If not, is there evidence that the CC has reasonably attempted to address objectives?


Question:
.--- Follow up on member issues are evident. (i.e. If member asked for assistance, did the care coordinator offer assistance and follow up to ensure needs were met.)


Question:
.--- If the notes indicate next steps for the Care Coordinator, then those next steps are documented. If the CC stated they would make a call or meeting was there documentation that those contacts took place (or documentation why they did not).


Question:
.--- Frequency of contact with the member was appropriate based on member needs. (i.e. If member had immediate complex needs such as an eviction did the care coordinator make additional contacts to ensure members needs were met.)


Question:
.--- If member went into crisis, documentation reflects crisis intervention activities. (Medical or Behavioral Health.)


Question:
.--- Based on individual needs and preferences, The care coordinator promotes wellness and prevention by linking the member with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services.


Question:
Was the MCO notified when the Member experienced barriers to service or when the Member experienced a significant event or change in status that would impact Member care (i.e., suicide attempt, housing disruption, step on or off HH+ services, etc.)?


Question:
Notes contain evidence of attempts to collaborate care with member's treatment team when appropriate. (i.e. If member reports feelings of suicidality  was the mental health provider notified.)


Question:
Case Conferences and Team Meetings are held when appropriate (per policy guidance).


Question:
If 60 days passed with no contact with the member, were they placed in diligent search? If the member was placed in diligent search prior to 60 days, were there at least 30 days with no contact despite meaningful attempts to contact?


Question:
(Above Diligent Search question does not apply to members who are incarcerated or in an excluded setting (extended) hospitalization.)


Question:
Was the Member's MCO notified of the status change, if applicable, during the first month of DSE?


Question:
Was the POC updated to reflect Diligent search activities that were relevant to the member?


Question:
Did the number of diligent search activities meet the minimum requirement to bill? (At least 3 different efforts.)


Question:
Were diligent search activities meaningful, progressive, and diverse?


Question:
If the Member was located while in DSE, did a conversation occur to attempt to re-engage the Member in Health Home Services?


Question:
Answer these questions for general ER / hospitalizations (will not be scored for high utilizers).


Question:
Care Coordinator responded to alerts of hospitalizations and ED visits – and any other events calling for the provision of Care Transition services within 2 business days of receiving the alert.


Question:
If reason for the visit could have been handled by primary care or urgent care, was the member given education regarding appropriate use of the emergency room.


Question:
If the ER visit or Hospitalization required aftercare such as a new provider, follow up appointments, changes in medications, etc. Then also answer the following.


Question:
Care coordinator assists member in following their discharge plan when transitioning back to the community.


Question:
.--- Discharge instructions from ER visits and hospitalizations are obtained and used to help member transition back to the community; appointments kept, meds obtained, etc. If not, does documentation show an attempt to obtain the discharge plan.


Question:
.--- Documentation shows that the care coordinator notified/collaborated with the care team upon notification of member’s transition to/from an ER/hospital/residential/rehabilitative setting (Providers/MCO).


Question:
.--- If member has social supports, support resources and persons were identified with member to assist in the time of crisis and aide in preventing future crisis.


Question:
.--- If member transitioned between criminal justice or any inpatient setting, was a warm handoff facilitated or an attempt to facilitate was documented. For inpatient stays, did the Care Coordinator attemped to collaborate with staff?


Question:
For Members Who are Considered High Utilizers


Question:
Care coordinator works with member to address barriers and root cause for repeat ER/IP utilization. (Such as connecting with outpatient care, meeting SDOH needs.)


Question:
Was there ongoing case collaboration with care team members (outside of formal case conferencing) to help address member needs and reduce utilization?


Question:
Is the member's high utilization addressed on the Plan of Care?


Question:
Was the member assigned to the HH+ program type in Care Manager?


Question:
Does the member have clear evidence of HH+ eligibility? (Current Eligibility form and Medical Records showing evidence are in the uploaded documents.)


Question:
For HIV HH+, at 6 months, a review of the POC and HIV assessment took place F2F at the members home. This included an eval of viral load and progress towards the objectives. This re-assessment of progress and status is written as a CM Note.


Question:
For HIV HH+, at six months a case conference took place with consented providers.


Question:
Did documentation in chart reflect a need for HH+ services? (Member meets acuity and appropriatness criteria for the HH+ program.)


Question:
Did the plan of care include objectives related to the reason the member qualifed for HH+ services?


Question:
Were the minimum core service delivery requirements met? (Member received at least 2 F2F core services and 2 other core services in the month.) If not, were actions taken to attempt to deliver core services.


Question:
Was the contact type and amount of contact appropriate based on member acuity. (For example, if member had acute needs that required more than two F2F core services, were core services delivered to ensure needs were met.)


Question:
The HH+ rate was only billed when appropriate.


Question:
Does the HH+ qualifying category on the HML match documented eligibility criteria?


Question:
A copy of the most recent and active AOT order is scanned into the documents of the chart.


Question:
The AOT member is identified as such in the Programs section of CareManager.


Question:
The Plan of Care includes all categories of service listed in the court-ordered AOT treatment plan.


Question:
The AOT member received 4 face to face core services per month (with documentation if unable to achieve).


Question:
If the AOT member was considered missing (no credibly reported contact within 24 hours of the Care Coordinator receiving notice that the person had an unexplained absence from an apt), were appropriate steps taken to seek out the member?


Question:
If the AOT member was considered missing (per above), was a missing persons report filed with the police within 24-48 hours?


Question:
Was there evidence of collaboration with providers identified in AOT Tx Plan, especially around non compliance with AOT Treatment Plan services?


Question:
The HARP Program type is correctly identified in the chart.


Question:
Staff perform HARP eligibility assessment or core referral at least annually or when there is a significant change in status for HARP (or notes indicate HARP services were declined).


Question:
If the eligibility assessment was completed and the member was interested in service, was there evidence that the LOSDR (service determination request/ the Preliminary Plan of Care) was sent to the MCO. (Uploaded request to documents.)


Question:
If notes indicated a LOSD response was received from the MCO, a copy of the MCO response is in the documents.


Question:
If member has an LOSD from the MCO, Is there documentation that steps were made to link the member to HCBS services.


Question:
If member has an LOSD from the MCO and is linked to services, then the full HARP POC is completed and a copy is attached in the documents.


Question:
Was a CareManager 'General Assessment' done for each key HARP activity noting the HARP activity done. Each key HARP activity should have both a note documenting the encounter and a General Assessment.


Question:
For all discharges, was the required discharge letter completed and sent to the member. If not, is there documentation of  why it could not be sent (i.e. no address).


Question:
If the member was discharged due to ineligibility, inappropriateness, or DSE, was the 5235 sent 10 days prior to closing. (Notice by means of Form DOH-5235 is required before the Health Home can disenroll.)


Question:
Does the reason for discharge selected reflect the reason for discharge in the discharge summary and notes.


Question:
For Members who were able to be contacted regarding the discharge, was the discharge discussed with the member prior to discharge to prepare member and ensure discharge readiness.


Question:
A discharge summary was completed for the discharge. This discharge summary contains a detail of events leading up to the discharge.


Question:
Was the summary shared or communicated to the care team members? (PCP, Mental Health Provider, Housing, MCO, etc.)


Question:
If there were unmet needs and discharge was able to be discussed with the member, was there evidence of discharge plan from Health Home program including referrals to services or programs.


Question:
///////OMIT ////////////Page 3 lists all individuals and/or entities with which PHI information sharing is evident (i.e. specific providers, Care team, family members, etc.)


Question:
The PCP and medical providers are identified in the chart/record


Question:
Behavioral health care providers are identified in the chart


Question:
Other community providers, supports involved in the individuals care are identified in the chart/record


Question:
Social Supports are identified as such in the chart.


Question:
Key identifiers are listed appropriately on the chart if found in the record. (suicide risk, staff safety concerns)


Question:
.-- The discharge summary contains a detail of events leading up to the discharge.


Question:
Documentation of transfer from CMA to CMA or HH to HH was done per policy? (if applicable)


Question:
The chart has evidence that the eligibility assessment was done appropriately:


Question:
.--- Notes indicate that the HARP eligibility assessment/reassessment was done in person with the member. (or indicate that the assessment was declined)


Question:
.-- Documentation reflects care management team provided follow-up post discharge with member/family to ensure member care plan needs/goals are met. (appointments kept, meds obtained, etc.)


Question:
Evidence that a letter of Introduction was sent.


Question:
.--- Intake assessment is completed in person with member


Question:
.--- HARP activities are addressed in the care plan. (if needed) (Goals/Interventions/Timeframes)


Question:
.--- Appropriate Core Service assigned to notes. (i.e. Care Manager notes for billable service)


Question:
.--- All notes marked as billable core services while enrolled meet the core service requirement for billing.


Question:
.--- IF NO, is there evidence that the CM acknowledged and has attempted to address need, regardless of if the member decided to engage in services?


Question:
.--- The plan of care intervention notes illustrate progress towards goal attainment.


Question:
The member was not re-consented. There is only one page 1 of the 5055. (Member should not be re-consented annually.)


Question:
Is the most recent 5055 the (3/18) version?


Question:
All client search notes marked as 'billable' meet or contribute to the activity requirement for billing for the month of outreach. (vs. Contact notes for non-billable)


Question:
Does the outreach billing assessment correctly reflect if billable services were provided?


Question:
Outreach months were used appropriately. (Member did not enter month 2 of outreach unless there was an expectation for a F2F meeting and if month 2 was used there is documentation of ongoing efforts to meet member F2F or member was met F2F)


Question:
Do all problems in the problems section of CareManager have an associated POC objective unless they are marked as resolved or 'Member chooses not to address'.


Question:
Is the POC member-centered? (i.e. The plan of care is individualized and specific to the member's needs. )


Question:
If the member was discharged,  was the DOH 5058 completed at discharge (withdrawal of consent), if not is there documentation of refusal to sign the consent or clear reason why it could not be signed. (Such as lost to service).


Question:
If member opted out of services prior to enrollment, is the opt out 5059 form completed and scanned in file.


Question:
.--- Assessments are finalized. (not left in draft status)


Question:
[For detox] An in-person visit was conducted while the member was in detox. If not, is there clear documentation of why a visit could not be made. (i.e. Detox program was outside of our service area)


Question:
[For detox] An in-person visit was conducted within 24 hours of the member being discharged from detox. If not, is there clear documentation of why a visit could not be made.


Question:
If the member remains in the HH+ program for over a year, is the eligibility reviewed and updated annually. (Eligibility form and Medical Records showing evidence are in the uploaded documents)


Question:
Was the MCO notified when the Member experienced a significant event or change in status that would impacr Member care (i.e., suicide atempt, housing disruption, etc.)?


Question:
.---- Member signature present with date on 1st page.


Question:
.---- Page 2 of 5055 is filled out correctly.


Question:
.---- Each line of consent has member initials approving each one.


Question:
.---- Each line of consent has the date of the initials approving each one.


Question:
.--- Scan of 5055 includes all three pages, and additional pages if needed.


Question:
The community health connections consent has been entered appropriately into CareManager.


Question:
First outreach attempt was within 5 business days of assignment.


Question:
A minimum of three engagement activities are conducted per month. (unless member enrolls or verbally opts-out)


Question:
For Community Referrals, was the referral source contacted within 2 business days.


Question:
For Community Referrals, was the referral source contacted regarding the decision to enroll or not.


Question:
For Community Referrals, are relevant documents scanned into the attached forms? (i.e. referral form)


Question:
.--- Intake assessment reflects current member needs (includes needs identified on the referral, in notes, or related to the members primary diagnosis).


Question:
.--- Explanations are given rather than using 'N/A' or 'not applicable'  and relevant questions are not left blank.


Question:
.--- Assessments are completed in person with member


Question:
.--- For the re-assessment, there is evidence that the assessment is updated annually as member conditions change. (i.e. If ER visits/suicide attempts occurred are those updated accurately.)


Question:
.--- Explanations are given rather than using 'N/A' or 'not applicable' and relevant questions are not left blank.


Question:
MMS form completed at the time of the initial comp assessment on all members not connected to BH services.


Question:
C-SSRS form completed if member has a recent history of suicidal ideation. (Suicidal attempt or ideation in the past year or in cases where member clearly remains a high risk for suicide or documented refusal of assessment.)


Question:
The Plan of Care contains at least one Physical or Behavioral Health objective.


Question:
The client goal statement is updated when goals change (if needed). (i.e. A goal statement related to obtaining a provider is updated after the provider has been obtained.)


Question:
Notes marked as CareManager notes clearly document that billable core service delivery was given.


Question:
Notes completed and finalized in a timely fashion. (Within 2 business days of contact.)


Question:
If member requested to change staff, agencies, providers, etc., was this request acted upon appropriately?


Question:
Potential conflicts of interest are avoided and appropriately handled. (i.e. When a referral to a provider is made, the member is given choices, not just referred to the agency's partner or other departments.)


Question:
.--- If the member had missed appointments, did the Care Coordinator follow-up on those missed appointments and problem solve with member on making future appointments.


Question:
If the ER/Hospitalization resulted in the need for new providers or significant change in needs, was the POC updated. (For example, a member who needs post-operative care following heart surgery should have this on the POC.)


Question:
Was the MCO notified when the Member began receiving HH+ services?


Question:
Was the MCO notified when the Member was stepped down from HH+ level of care?


Question:
If the HARP eligibility assessment was done, then an attached document contains the summary of the eligibility assessment/reassessment.


Question:
If member was interested in HCBS services, were HARP activities on the POC. (Objective/Interventions/Timeframes)


Question:
For members graduating off service, was the plan of care updated to reflect objectives being met/objective status?


Question:
For member's who are actively participating in the discharge, the plan of care is reviewed with the member at discharge.


Question:
(((DUP)))Did a case conference take place to address high utilization?


