# Form_01

Question:
Forms and Documents - Check in Attached Documents


Question:
At the time of POC review, there is a signed acknowledgment form or electronic signature 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 DOH 5235 sent 10 calendar days prior to closing. (Notice by means of Form DOH 5235 is required before the Health Home can disenroll.)


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 an 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:
If the case was transferred after January 1, 2025, was the Member re-consented with a new DOH 5055 within 90 days of the transfer?


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


Question:
Initial Comprehensive assessment is done face-to-face, unless there is documented telehealth approval from the Member.


Question:
CAGE-AID was completed prior to Initial Plan of Care creation.


Question:
The plan of care is completed within 60 days of enrollment.


Question:
Need(s) identified from the Initial Appropriateness Screening are addressed in the care plan.


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:
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 Member's primary diagnosis, 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.)


# Form_05

Question:
Annual Reassessment: Comprehensive Assessment is made 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 (Reflects current needs / updates).


Question:
Comprehensive Assessments was done face-to-face, unless there is documented telehealth approval from the Member.


Question:
The SDOH Assessment is done with the Member, annually.


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 reviewed at least annually, using the Annual plan type in CareManager.


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


Question:
At the time of POC review, there is a signed acknowledgment form or electronic signature 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:
Member strengths, barriers to care, and history/risk factors are identified on the plan of care. (This should match or relate to information from the comp assessment or as 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; target dates are staggered and not all set to the same date. Longer 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 (if needed). (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 the Member had not been in contact with agency staff for 60 days despite contact attempts, were they placed in DSE OR had a CES Tool completed?


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 the 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:
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:
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 the 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 the 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 the Member on making future appointments?


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


Question:
.--- Over the past six months, there is 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-related issues is evident. (i.e. If the 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, 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 the Member had immediate complex needs such as an eviction did the care coordinator make additional contacts to ensure the Member's needs were met.)


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


Question:
.--- Based on individual needs and preferences, the CC 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 with the Member's treatment team when appropriate. (i.e. If the Member reported feelings of suicidality was the mental health provider notified.)


Question:
Case Conferences and Team Meetings are held when appropriate (per policy guidance). (Be sure to note specific details.)


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:
If 60 days passed with no contact with the Member, were they placed in DSE OR had a CES Tool completed? If the Member was placed in DSE 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 Annual POC was updated while the Member was in DSE, then were efforts made to engage the Member in updating the POC once the member is reconnected with service. (POC is updated, and acknowledgment form signed/electronic signature captured.)


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:
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_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 a CORE referral was submitted, was there evidence of follow up to ensure linkage to services.


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 an 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:
If a General Assessment was completed, is there a corresponding note that reflects the HARP discussion?


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 CareManager?


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 six months, a review of the POC and HIV assessment took place F2F at the Member's 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 appropriateness criteria for the HH+ program.)


Question:
Did the plan of care include objectives related to the reason the Member qualified 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, actions were taken to attempt to deliver core services.


Question:
Was the contact type and amount of contact appropriate based on the Member's acuity. (For example, if the 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 person's report filed with the police within 24-48 hours?


Question:
Was there evidence of collaboration with providers identified in AOT Tx Plan, especially around noncompliance 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 at the time of the Care Transition if new needs were identified OR other circumstances change that warranted a Plan update?


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 the 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 the 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 attempted to collaborate with staff?


Question:
For Members Who are Considered High Utilizers


Question:
Care coordinator worked with the 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 the Member's 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 to address the Member's high utilization of hospital/ED services (per policy guidance). (Be sure to note specific details.)


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, the required discharge letter was completed and sent to the Member. If not, 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 DOH 5235 sent 10 calendar 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, the discharge was 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 details of events leading up to the discharge.


Question:
Was the summary shared or communicated with 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:
Click the "Change/Set Backup Location" button.


# 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:
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)

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


Question:
If the case was transferred after January 1, 2025, was the Member re-consented with a new DOH 5055 within 90 days of the transfer?


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


Question:
Initial Comprehensive assessment is done face-to-face, unless there is documented telehealth approval from the Member.


Question:
CAGE-AID was completed prior to Initial Plan of Care creation.


Question:
The plan of care is completed within 60 days of enrollment.


Question:
Need(s) identified from the Initial Appropriateness Screening are addressed in the care plan.


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:
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:
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 Member's primary diagnosis, etc.)


Question:
Annual Reassessment: Comprehensive Assessment is made 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 (Reflects current needs / updates).


Question:
Comprehensive Assessments was done face-to-face, unless there is documented telehealth approval from the Member.


Question:
The SDOH Assessment is done with the Member, annually.


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


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


Question:
At the time of POC review, there is a signed acknowledgment form or electronic signature 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:
Member strengths, barriers to care, and history/risk factors are identified on the plan of care. (This should match or relate to information from the comp assessment or as 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; target dates are staggered and not all set to the same date. Longer 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 (if needed). (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:
If the Member had not been in contact with agency staff for 60 days despite contact attempts, were they placed in DSE OR had a CES Tool completed?


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 the 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:
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:
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 the 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 the 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 the Member on making future appointments?


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


Question:
.--- Over the past six months, there is 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-related issues is evident. (i.e. If the 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, 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 the Member had immediate complex needs such as an eviction did the care coordinator make additional contacts to ensure the Member's needs were met.)


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


Question:
.--- Based on individual needs and preferences, the CC 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 with the Member's treatment team when appropriate. (i.e. If the Member reported feelings of suicidality was the mental health provider notified.)


Question:
Case Conferences and Team Meetings are held when appropriate (per policy guidance). (Be sure to note specific details.)


Question:
If 60 days passed with no contact with the Member, were they placed in DSE OR had a CES Tool completed? If the Member was placed in DSE 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 Annual POC was updated while the Member was in DSE, then were efforts made to engage the Member in updating the POC once the member is reconnected with service. (POC is updated, and acknowledgment form signed/electronic signature captured.)


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:
Is there evidence that the care plan is being updated at the time of the Care Transition if new needs were identified OR other circumstances change that warranted a Plan update?


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 the 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 the 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 attempted to collaborate with staff?


Question:
For Members Who are Considered High Utilizers


Question:
Care coordinator worked with the 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 the Member's 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 to address the Member's high utilization of hospital/ED services (per policy guidance). (Be sure to note specific details.)


Question:
Was the Member assigned to the HH+ program type in CareManager?


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 six months, a review of the POC and HIV assessment took place F2F at the Member's 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 appropriateness criteria for the HH+ program.)


Question:
Did the plan of care include objectives related to the reason the Member qualified 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, actions were taken to attempt to deliver core services.


Question:
Was the contact type and amount of contact appropriate based on the Member's acuity. (For example, if the 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 person's report filed with the police within 24-48 hours?


Question:
Was there evidence of collaboration with providers identified in AOT Tx Plan, especially around noncompliance 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 a CORE referral was submitted, was there evidence of follow up to ensure linkage to services.


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 an 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:
If a General Assessment was completed, is there a corresponding note that reflects the HARP discussion?


Question:
For all discharges, the required discharge letter was completed and sent to the Member. If not, 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 DOH 5235 sent 10 calendar 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, the discharge was 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 details of events leading up to the discharge.


Question:
Was the summary shared or communicated with 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?


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:
.--- Need(s) identified from the Initial Appropriateness Screening are addressed in the care plan. (Objective/Interventions/Timeframes)


Question:
CAGE-AID completed prior to Initial Plan of Care creation.


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


