| 1. Range of care team function and expertise that can be mobilized to address needs of particular patients and target populations:
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1. Range of care team functions
Lacks foundational functions – does not fulfill baseline functions required by the state Foundational functions – fulfills baseline functions (initial evaluation, regular monitoring and adjusting of individual care plan goals, population health management) Foundational plus – fulfills baseline functions and at least 2 additional functions (e.g., medication management, tracking lab tests) Extended functions – fulfills baseline functions and at least 4 additional functions 2. Range of expertise in core health home team
Lacks foundational care team expertise – does not fulfill baseline staffing required by the state Foundational care team expertise – fulfills baseline staffing (director, nurse care coordinator, primary care consultant) Foundational plus – fulfills baseline staffing and includes PRP, mental health, and social service staff as core members of health home Extended care team expertise – fulfills baseline staffing and includes PRP, mental health, substance use treatment, and multiple social service staff as core members of health home team
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2. Type of spatial arrangement employed
Mostly separate space Co-located space Fully shared space
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3. Spatial arrangement of each provider type with the health home: primary care providers; mental health providers; substance use treatment providers; supported housing staff; supported employment staff (5 sub-measures)
Completely separate space – consumers cannot walk to provider offices and health home does not provide transportation Mostly separate space – consumers can walk to provider offices or health home provides transportation Co-located space – consumers receive services in same building as health home
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3. Type of collaboration employed
Referral-triggered periodic exchange Regular communication/coordination Full collaboration/integration
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4. Communication and information-sharing strategies employed by health home with each provider type: PRP staff; primary care providers; mental health providers; substance use treatment providers; supported housing staff; supported employment staff; criminal justice staff (7 sub-measures)
No or minimal communication – No mutual exchange of information (may be one-sided or nonexistent) Referral-triggered periodic exchange – Health home and other provider at least sometimes notify one another when consumer status changes Regular communication – Health home and other provider have regularly scheduled meetings at least once/month Full collaboration – Health home and other provider have regularly scheduled meeting at least once/month, often notify one another often when consumer status changes, and use additional communication strategies to keep in touch
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| 4. Method for identifying individuals who need integrated behavioral health and medical care |
Not applicable to the health home setting; all Medicaid beneficiaries participating in psychiatric rehabilitation programs were eligible |
5a. Protocols in place or not for engaging patients in integrated care
Protocols not in place Protocols in place 5b. Level that protocols are followed for initiating integrated care
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5. Consumer engagement protocols
No or minimal protocols in place – no materials to guide care Moderate level of protocols in place – conducts initial evaluation of consumer needs and uses printed materials to guide care Significant protocols in place – conducts initial evaluation of consumer needs and uses printed materials and electronic decision support tools to guide care
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6a. Proportion of patients in target groups with shared care plans
< 40% 40% to nearly 100% Nearly 100% 6b. Degree that care plans are implemented and followed
< 50% > 50% but < 100% Nearly 100%
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6. Access to consumer health data
No or very limited access to consumer data Limited access to consumer data – has at least some access to at least two of the following: enrollees’ EMR; unmet health needs; functional impairments and disabilities; primary care provider notes; psychiatrist notes Moderate access to consumer data – has at least some access to all of the following: enrollees’ EMR; unmet health needs; functional impairments and disabilities; primary care provider notes; psychiatrist notes Full access to consumer data – has full access to all of the above information 7. Access to consumer social data
No or very limited access to consumer data Limited access to consumer data – has at least some access to at least two of the following: enrollees’ unmet social needs; housing; employment; income Moderate access to consumer data – has at least some access to all of the following: enrollees’ unmet social needs; housing; employment; income Full access to consumer data – has full access to all of the above information 8. Comprehensiveness of shared care plans for consumers
No comprehensive care plan for consumers Care plan present but limited in scope Multi-component care plan – comprehensive care plan includes plans for somatic care and social services, participant preferences, and behavioral health treatment Care plan with extended components – comprehensive care plan includes multi-component elements and at least 5 additional items (e.g., community networks and supports, plans for preventing recidivism, health behavior change – see Appendix B for full list)
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| 7. Level of systematic follow up
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9. Systematic follow-up of consumers
No monitoring of care plans Monitoring and adjustment of care plans at least twice/year Monitoring and adjustment of care plans at least twice/year and following up on tests and referrals
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