Archived Questions and Answers

Quality Metrics and Evaluation (CMART)

Table of Contents

  1. What will be the clinical/quality outcomes tracking tool?
  2. Do we have to use the FACT–GP Assessment posted on the Health Home website?
  3. If someone is already in case management through another mechanism with a Health Home entity, can we use an existing baseline risk assessment or are we required to complete a new Health Home baseline risk assessment?
  4. Does the assessment have to be conducted only face–to–face or can it be conducted telephonically as well? Face–to–face requirement is a potential obstacle to expeditious enrollment. Also it is unlikely that someone who self disenrolls from a Health Home will be available/willing to complete a functional assessment.
  5. How do we access the FACT–GP score for the homeless?
  6. Are Care Coordination agencies to enter the FACT–GP data and when should this occur?
  7. When do we use the required Health Home tools (for example the functional assessment) with Legacy clients?

Back to current Q&As

1. What will be the clinical/quality outcomes tracking tool?

The New Core Set of Quality Measures (the comprehensive list of quality measures the State will track) is available in the SPA by clicking here.

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2. Do we have to use the FACT–GP Assessment posted on the Health Home website?

Yes, all Health Homes must use the FACT–GP functional assessment and the Health Home Questionnaire but are also able to use other additional assessment tools the Health Home finds useful.

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3. If someone is already in case management through another mechanism with a Health Home entity, can we use an existing baseline risk assessment or are we required to complete a new Health Home baseline risk assessment?

For a member entering a Health Home, a FACT–GP and HH Functional Assessment must be completed at enrollment, annually and at disenrollment. These will be reported to the State through the HH–CMART tool that will be released shortly. The results of these assessments will be used to adjust the risk scoring for members and, through that, the applicable rates. These are limited tools and do not take the place of the comprehensive assessment needed to develop a care management plan for the member. The care manager should use all resources that are available for that member to ensure the most appropriate care management plan is formulated including information from previous care management. We would also expect care managers to use validated assessment tools most appropriate to the member´s situation.

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4. Does the assessment have to be conducted only face–to–face or can it be conducted telephonically as well? Face–to–face requirement is a potential obstacle to expeditious enrollment. Also it is unlikely that someone who self disenrolls from a Health Home will be available/willing to complete a functional assessment.

The FACT–GP and HH Functional Assessment as well as the comprehensive assessment must l be conducted face to face. If at disenrollment it is not possible to do these face to face, telephonically could be allowed.

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5. How do we access the FACT–GP score for the homeless?

Question HH6 is scored on a Yes and No basis. 8 points is scored for NO and 0 is scored for YES. A higher score represents better health, a score of "0" indicates that the member was homeless in the last 7 days; if they are housed, the score is "8". Official scoring guidelines for the FACT–GP and Health Home Functional Questionnaire, which include some reverse scoring methods, can be found here.

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6. Are Care Coordination agencies to enter the FACT–GP data and when should this occur?

The FACT–GP Health Home assessment should be done by the Care Manager or a delegate of the Care Manager. Aggregate scores will be reported to the lead Health Home as part of the Health Home CMART process metrics data collection process.

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7. When do we use the required Health Home tools (for example the functional assessment) with Legacy clients?

These should be utilized for existing members as soon as possible, and used upon enrollment for new members. Please use the appropriate language translated forms.

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