New York State DOH Health Home Care Management Reporting Tool (HH-CMART) Support Calls – Session #5 March 20,2013 1

 Technical Specifications Update  Q+A Themes from previous calls  Reminder: HH-CMART Data Flow  Definitions of Elements 27–34  Questions and Comments  Feedback, Help, and Ongoing Support 2

 Please submit your questions in writing to the webinar  If you would like to ask your questions, raise your hand (making sure you have entered your audio pin code) and we will unmute the call one at a time  We are working on a Question and Answer document that will be posted on the HH website under the HH-CMART section 3

Question and Answer Themes  Can more than one person enter data at the same time in the HH CMART tool if the tool is placed on a shared drive?  The HH CMART tool can reside on a shared drive, and two or more people can enter the data at the same time on different individuals. But two people cannot enter data for the same individual at the same time. 4

 Does the FACT GP / HH Functional assessment scores need to be submitted from ‘converting to health home’ legacy members and all other Health Home members enrolled in 2012?  Yes, the FACT GP/ HH Functional assessment scores are required to be submitted for all converting TCM clients and other active members of HH for 2012  How do I submit the 2012 Fact GP/ HH Functional assessment scores?  The Health Home and the Care Manager / downstream provider should develop a process using the excel spreadsheet DOH sent out. See 3/13/2013 webinar, slides 4, 6,& 7 for more information or contact for a 5

 Can care manager / downstream provider share data from the Fact GP/ HH Functional Assessments with a Health Home when the clients are ‘case closed’ and/ or a withdrawal of consent was signed?  Retraction of Exception on Slide 9 from 3/6/13 Webinar: After consultation with DOH legal (DLA), there is no longer an exception to sharing FACT GP/ HH Functional Assessment Data. Signed withdrawal of consent does not prohibit the Care Manager (CM) from sharing data with Health Home(HH)  Upcoming HH webinar for Q’s on sharing data & terms of the DEA & Subcontractor packet  CM downstream provider assessment data can be shared with the HH as long as there is an agreement (Subcontractor packet ) between the HH and CM downstream provider. 6

7  If 2012 HH members do not have completed initial FACT-GP / HH Functional assessments  You do not need to report using the excel spreadsheet or the CMART tool for the TCM legacy clients and other HH members served during 2012  What does the care manager or HH do if I the 2012 FACT GP/ HH Functional Assessments were not done?  Go Forward: Perform initial FACT GP/ HH Functional assessments now on any converting TCM member or Health Home member currently receiving services and enter it into the HH CMART tool  Submit assessment scores with all other HH CMART data to the Health Home for first two quarters of 2013 – (see report schedule for the August 5 th submission date)

F Question and Answer Themes From March 13 Call  How do I submit the first two quarters of 2013 HH CMART data, due August 5 th, 2013 ?  CM & HH must discuss / plan how to collect & then export the data to the HH  Collection / Export suggestions:  CM should use a separate HH CMART tool  Or use a separate HH CMART export template spreadsheet  Or whatever method HH & CM agreed upon  Once compiled, CM sends it to HH’s you have an agreement with so the HH can report it to NYS DOH 8

 Care Management Providers: Collect the data needed for HH-CMART submission, (either in the HH-CMART tool or in the excel template file) using the specifications and response options for each element. ◦ For any care management provider managing members for more than one Health Home, multiple HH-CMART files can be used. Make a copy of the HH CMART Tool to use for each of the health homes separately prior to entering any data. You should not use the same health home CMART Tool for entering more than one health home’s data. ◦ At the end of the reporting period, the care management provider securely transmits a file to each Health Home, containing the data for that Health Homes members.  Health Homes: gather the HH – CMART data from all care management providers for their members and aggregate all of the data files into ONE Health Home file. The Health Home’s single file is imported into one HH-CMART tool for that reporting period.  A single HH-CMART export file ( compilation of all CM providers/ partners) for the Health Home is sent to DOH by the Health Home via the Health Commerce System. 9 Care managers will provide needed information about services provided to the Health Home Health Home collects data from all care management staff involved with its members Health Home enters or imports data for all members assigned to the Health Home into the tool and submits HH-CMART to DOH Care Manager Collects Health Home compiles Health Home submits to SDOH *Flow diagram reference: HH CMART Technical Requirements Specification document, page 4

Each element is color coded by data collection needs for each element by reporting period ◦ Green = changes each reporting period ◦ Red = Once in, remains the same always ◦ Orange = Needs to be reviewed for new information each report ◦ Blue = DOH will fill in * Color Coding See slides from Feb. 20, 2013 Webinar power point: m/medicaid_health_homes/meetings_webinars.htm 10

11 27 –CaseReopened: Indicates whether a member is located and reengaged in care management after case closure. ◦ This element should indicate ‘REOPENED’ if there is a subsequent engagement of care management initiated during the reporting period, regardless of program or reason for care management. ◦ The reopening of the case will be documented in the CaseReopened field in the appropriate quarter reporting period when the reopening occurs. Distinguishing when care management is reopened – ◦ If care management services for the member has been closed (due to inactivity or other reason) and, for example, the health home policy for case reopened is to conduct a new assessment and start a new care plan during the reporting period, then this should be considered a “reopening” of care management and CaseReopened should be ’REOPENED’. Note :Care managers should follow the Health Home policy for case reopened guidelines and determination. ◦ If care management has been closed and the subsequent reopening of care management does not start during the reporting period, the case should be considered closed and CaseReopened should be “NOT REOPENED” for that reporting period. ◦ If care management has been inactive, and the member is located and engaged and the same assessment and care plan are used, then these activities should be considered part of the initial care management segment. In this situation, CaseReopened would be blank because the care management was never closed. 28 – DateReopened: Date when a member is reengaged in care management after case closure. ◦ The DateReopened will be determined through the Patient Tracking System. The date of the case reopened will be after a segment that is the first ‘Begin Date’ following an ‘End Date’ in the Patient Tracking System.

 Identifying, categorizing and counting care management interventions (Elements 29-34) ◦ Each separate intervention should be counted once for an appropriate category. ◦ Only interventions which were conducted should be counted; updates scheduled but not completed should not be included. ◦ The counts of interventions reported for a member should be limited to the reporting period and should not include interventions from any other reporting periods. Counts are not cumulative from the initiation of care management. ◦ The activities conducted during the reporting period for care management may involve the member and legal representative/family, the health care providers, or other community based services. The interventions should be specific to the individual member’s care or care management needs. ◦ Interventions delivered by all care management staff (care managers and support staff) should be included. ◦ Interventions conducted by Health Home or care management contracted vendors should be counted. ◦ Interventions conducted by providers, other organizations, or health plans should not be counted. 12

Element Definitions  Many times interventions will include a multiple focus. Select which category that represents the primary reason for the intervention and include in the count for that category.  Example: a FTF visit includes assessing a new need and during that visit, assistance to make an appointment for the need is provided. Primary reason for the intervention is assessing new need, so intervention is included in CareManage for the reporting period.  Count = 1 for CareManagement

 29 – Plan Update: Indicates whether the member’s care plan was reviewed, updated and/or modified during the reporting period. ◦ Captures an indicator of whether the member’s care plan was reviewed, updated and modified, if necessary, at least once during the reporting period.  30 – CareManage: Counts of activities in the reporting period to assess needs, monitor progress with member/legal representative and care team, modify or update the care plan or goals. ◦ Captures the count of interventions for comprehensive care management activities (gathering) information about needs or progress, revising or modifying the care plan, and interacting with member and providers about modifications to the care plan) conducted for or with the member during the reporting period.  31 – HealthPromote: Counts of activities in the reporting period to assist in scheduling and keeping appointments, advocate and arrange for needed services and monitor delivery of services. ◦ Captures the count of interventions for health promotion activities (assistance in scheduling and keeping appointments, advocating for services and arranging services) conducted for or with the member during the reporting period. 14

 32 – TransitionCare: Counts of activities in the reporting period to evaluate care needs at transitions, arrange safe transition plan, update care team, update information with providers and care plan ◦ Captures the count of interventions for addressing transitions in care (evaluating care needs, safe transition plan, continued care arrangements and updating providers and care plan) conducted for or with the member during the reporting period.  33 – MemberSupport: Counts of activities in the reporting period to self – management, family/legal representative meetings, peer supports, educate member rights ◦ Captures the count of interventions for providing member/family supports (self‐management education, conducting family meetings, arranging peer or community support programs, and educating member on rights) conducted for or with the member during the reporting period.  34 – CommSocial: Counts of activities in the reporting period to collaborate with Community Based Organization for services or needs. ◦ Captures the count of interventions for addressing community based services (arranging and coordinating community based services and supports) conducted for or with the member during the reporting period. 15

 We encourage your feedback ◦ Case Scenario development ◦ Clarify fields so that the thinking behind how a question is answered in the HH-CMART is the same across the board  the Health Home Team at with the Subject : HH CMART Or Call the Health Home provider line –  Health Home website, Assessment and Quality Metrics menu, Process Measures section: _health_homes/assessment_quality_measures/process_measures.ht m 16

 Weekly call every Wednesday from 10 a.m. to 11 a.m. ◦ The next call for March 27 th, 2013 will be announced via and information will be posted on the HH Website under “What’s New” menu  Slides from all webinars can be accessed by visiting the Health Home website at: dicaid_health_homes/meetings_webinars.htm 17