Health Home High-Fidelity Wraparound for Children/Youth with Serious Emotional Disturbance - Eligibility and Care Management Requirements
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Policy Title: Health Home High-Fidelity Wraparound for Children/Youth with Serious Emotional Disturbance - Eligibility and Care Management Requirements
Policy Number: HH0022
Effective Date: January 1, 2025
Last Revised: February 27, 2025
Approved By:
Contents
Applicability
Purpose
Background
HFW Eligibility Criteria
HFW Eligibility Determination for Children/Youth Enrolled in HHSC
HFW Eligibility Screening Criteria
Care Management Requirements
Reassessment & Continued Enrollment in HFW
Disenrollment from HFW
Appendix
Applicability
This policy only applies to Health Homes Serving Children (HHSC) Care Management Agencies (CMA) that have been approved and designated by the Office of Mental Health (OMH) and employ New York State (NYS) High-Fidelity Wraparound (HFW)-Certified Care Manager(s) (CM). Click here for a listing of approved HFW CMAs.
CMs must adhere to all issued Health Home policies and procedures aside from Diligent Search Efforts. Diligent Search Efforts are not applicable to the HFW Program because that is not an expectation in HFW.
Purpose
This policy outlines the High-Fidelity Wraparound (HFW) Program and the criteria for a child/youth to be eligible to enroll in the program. This includes how to determine a child/youth's eligibility, care management requirements for children/youth enrolled in HFW, continued enrollment in or disenrollment from HFW.
Background
HFW is a research oriented, evidence-based care management approach that has been proven successful with children/youth with Serious Emotional Disturbance (SED) who have significant mental health needs, including cross-system needs, that have led to the child/youth being admitted to or at imminent risk of long-term hospitalization or out-of-home placement and treatment.
HFW Eligibility Criteria
To be eligible to enroll in HFW, the child/youth must meet each of the following criteria:
- Health Home (HH) Enrolled/Eligible through either Serious Emotion Disturbance (SED) determination OR two (2) Mental Health (MH) diagnoses (Reference Appendix A)
AND - Must be 6 - 21 years old upon HFW enrollment
AND - The child/youth's acuity is determined to be Complex (High) based upon the Child Adolescent Needs and Strengths (CANS-NY) assessment AND
- A. Within the last year, the child/youth (A) has been involved with and transitioned from at least one (1) of the below programs, services, or facilities and/or (B) is currently receiving or enrolled in at least one (1) of the following services or programs and is expected to transition back to their community within the next 30 days:
- Out-of-home care and treatment (e.g., State psychiatric center, psychiatric inpatient hospital, Residential Treatment Facility, Children's Community Residence, Residential Substance Used Disorder (SUD) Treatment, Juvenile Justice Residential Placement, Residential Treatment Center, etc.)
- Intensive care/treatment for SED (e.g., Partial Hospitalization, Children's Day Treatment, Youth Assertive Community Treatment (ACT), Home and Community Based Services (HCBS) Waiver with K3 code (enrolled under SED))
- Two (2) or more crisis responses due to mental health challenges (e.g., emergency room visit, mobile crisis response, Children's Crisis Residence, Home Based Crisis Intervention (HBCI), Mobile Integration Team (MIT)
- Foster Care placement (QRTP, VFCA, etc.)
- B. The child/youth is currently going through the application process or on the waitlist for Youth ACT or out-of-home care and treatment (e.g., State psychiatric center, psychiatric inpatient hospital, Residential Treatment Facility, Children's Community Residence (CCR), Residential SUD Treatment, Juvenile Justice Residential Placement, Residential Treatment Center, etc.); or has been found eligible for Residential Treatment Facilities (RTF) level of care.
AND - The child/youth is involved with two (2) or more systems
- Two (2) or more systems could include: Child Welfare: Child protective services, preventive services, or foster care; Juvenile Justice Services: Arrest, Persons in Need of Supervision (PINS) petition, aftercare, probation, or parole; Complex Health: Chronic and severe medical condition that requires ongoing specialized care; Mental Health: In receipt of a service(s) for a diagnosed mental health disorder; Substance Use: In receipt of a service(s) for a diagnosed substance use disorder; School: 504 Plan (directly related to a BH need), Individualized Education Plan (IEP)/Behavior Plan (directly related to a BH need); Intellectual or Learning Disabilities: In receipt of a service(s) for a diagnosed intellectual/learning disability.
HFW Eligibility Determination for Children/Youth Enrolled in HHSC
To support the identification of children/youth that may benefit from HFW who are enrolled in HHSC, an HFW eligibility screening is integrated within the Uniform Assessment System (UAS) and linked to the CANS-NY assessment. The screening is automated and will only appear if the CANS-NY Care Coordination level of support determines that the child/youth meet Complex (High) acuity, if not already enrolled in HFW.
If the child/youth is determined Complex acuity, a question regarding if the child/youth have an SED or two (2) MH will need to be answered to trigger the HFW screening questions. The screening is a series of questions that the care manager will be prompted to answer to determine eligibility based on the HFW Eligibility Criteria, noted above. The care manager must answer these questions to determine HFW eligibility and have supporting documentation (verification of SED/two (2) MH diagnosis, verification of service utilization within the last year) to support the responses at the time of completion or be able to provide the supporting documentation prior to HFW transition. The CANS-NY assessment cannot be finalized until the HFW screening is completed.
The child/youth's HFW eligibility result will be determined upon completion of the screening and finalization of the CANS-NY and will be displayed on the HFW Eligibility line of the “Assessment Outcomes” section of the UAS. If the eligibility result is “No, not eligible” then the child/youth does not meet the criteria for HFW, and services should continue with the current Health Home care manager. If the eligibility result is “Yes, eligible”, then the child/youth is determined eligible for HFW, and action must be taken by the HH care manager to the HFW process and is dependent upon HFW availability.
The eligibility determination produced from this assessment will remain valid for one (1) year. The eligibility determination does not need to be removed from the UAS if the child/youth and/or family caregiver choose not to participate with HFW.
HHs and CMAs should have policies and procedures in place to guarantee that supporting documentation is on file for a child/youth prior to enrollment in HFW. In addition to supporting documentation, a signed HFW Agreement Form (DOH-5817) must also be on file prior to enrollment.
The chart on the next page identifies the questions, associated responses, and help text contained in the HFW Eligibility Assessment in the UAS.
HFW Eligibility Screening Criteria
In addition to receiving care management services that meet the requirements outlined in “Health Home Standards and Requirements for Health Homes, Care Management Agencies, and Managed Care Organizations”, children/youth and families enrolled in HFW receive:
- The required caseload ratio for HFW is one (1) full-time equivalent (FTE) HFW Certified HHSC Care Manager to ten (10) HFW recipients. HFW Certified Care Managers must be supervised by a HFW Certified Supervisor. A HFW Certified Supervisor can supervise up to 5 HHSC care managers. This can be a combination of HFW-certified Care Managers and traditional HHSC care managers.
- Timely Engagement and Planning.
- To meet fidelity requirements, initial contact with the child/youth, and family occurs within three (3) days of case assignment, and the first in-person contact occurs within ten (10) days. The initial Child & Family Team Meeting (CFTM) is held within 30 days of the first in-person meeting, where the initial plan of care (POC) is created. Additional CFTMs occur monthly, with no greater gap than 35 days.
- Intensive care coordination.
- At least four (4) completed core services/month, including one (1) Child and Family Team Meeting (CFTM). Each of the four (4) core services must include contacts with the enrolled child/youth/caregiver. CFTMs are structured to involve the child/youth and caregivers in leading the development, implementation, and monitoring of their POC, fostering collaboration among the family, natural supports, and service providers to address the family's needs and strengths.
- Multi-system support and service coordination.
- A Child and Family Team (CFT) is formed with family, friends, community members, and service providers selected by the child/youth and family. The team develops and monitors a single plan of care (POC) that is holistic and individualized to the specific needs of the child/youth and family. The care manager facilitates monthly CFTMs and ensures ongoing communication between CFTMs among team members. Natural and community supports play a key role, and strategies are implemented within the child/youth's and family's community whenever possible. All team members share responsibility for their tasks to meet the needs of the child/youth and family.
- Individualized service planning.
- Planning is driven by the child/youth's and family's culture, strengths, interests, and skills. The child/youth's and family's perspective are central to decision- making and problem-solving. A Family Vision is created to define desired outcomes, and a Family Story documents the child/youth's and family's experience, guiding the CANS-NY assessment and service planning. Services focus on addressing prioritized underlying needs, and progress is regularly reviewed to adjust the care plan as needed. Transition skills, such as planning, advocacy, maintaining supports, tracking progress, and crisis management, are incorporated from the beginning of the process to support the child/youth and family in transitioning successfully from HFW.
- Access to family and child/youth peer support.
- HFW care management agencies (CMAs) must provide or have a demonstrated partnership with Child and Family Treatment and Support Services (CFTSS) State designated providers of Youth Peer Support and/or Family Peer Support Services to be able to refer and connect children/youth and families enrolled in HFW.
Reassessment & Continued Enrollment in HFW
HFW is a short-term intervention that is implemented across four (4) phases of effort.
- Engagement: relationships are established, the strengths, needs, and supports of the child/youth and family are identified, and the tone is set for teamwork and team interaction.
- Plan Development: facilitate the Child & Family Team (CFT) in the creation of the initial plan of care addressing the family's needs and choices
- Plan Implementation: ensure the plan of care is being implemented as intended, and that the CFT is monitoring and reviewing progress at every CFTM. Facilitate the CFT to update and revise the plan when needed.
- Transition: share progress, celebrate successes and accomplishments, and plan for a purposeful transition from HFW.
While the time it takes for each child/youth and family to complete the four (4) phases is individualized to them, the average length of stay is between ten (10) and eighteen (18) months.
Each phase focuses on supporting an effective planning process to empower the child/youth and family to reach their goals. The CANS-NY assessment supports POC development and provides a standardized approach to monitoring progress. For those reasons, the CANS-NY reassessment is completed every six (6) months for children/youth enrolled in HFW. However, the CANS-NY is not used to determine continued eligibility for HFW. Once a child/youth is enrolled in HFW, they remain enrolled regardless of the changing CANS-NY acuity rating. The acuity rating of the child/youth may drop from Complex at initial enrollment to either Intense or Standard acuity at subsequent reassessments and the child/youth may remain enrolled until completing the four (4) phases and graduating or choosing to disenroll.
Once a child/youth has completed the four phases and graduated, they should not remain enrolled in HFW, as their progress and needs have evolved. Upon graduation, they can transition to a lower level of care management, which will help them maintain the skills and successes they have achieved during their time in the program. If they no longer require ongoing support, they can transition out of the HHSC program entirely. This approach ensures that children/youth receive the appropriate level of care and resources based on their current needs, supporting their continued growth and independence. The Lead HHs will monitor the length of stay for children/youth enrolled in HFW and provide OMH with a report quarterly. OMH will work in collaboration with the Lead HH and DOH to assure that children/youth are appropriately transitioned/discharged post HFW graduation.
Disenrollment from HFW
A child/youth and family officially graduate from HFW upon completion of the four (4) phases of the model. At times and for various reasons, a child/youth and family may decide they no longer want to participate in this voluntary program prior to graduation. Once the child/youth and their family have indicated that they would like to graduate or disenroll, the HFW CM must inform the Lead HH and conduct an early reassessment of the CANS-NY, as HFW program requires a discharge CANS-NY. The HFW CM will choose “Significant Life Event” and “Discharge from High-Fidelity Wraparound” as the reason code for this assessment. Then the HFW CM will disenroll the child/youth from the HFW and HH program following the current “Member Disenrollment From the Health Home Program” policy.
If the child/youth and family would like to remain in Health Home program, then the HFW Supervisor, and Lead HH (Current HFW CMA) will coordinate a step-down to another CM/CMA for Health Home only for care management.
Any questions should be submitted to OMH.HFW@OMH.NY.GOV
Appendix
Health Home Serving Children Serious Emotional Disturbance (SED) Definition
For Health Home Serving Children, SED is a single qualifying chronic condition and is defined as a child or adolescent (under the age of 21) that has a designated mental illness diagnosis in the following Diagnostic and Statistical Manual (DSM) categories below* as defined by the most recent version of the DSM of Mental Health Disorders AND has experienced the following functional limitations due to emotional disturbance over the past 12 months (from the date of assessment) on a continuous or intermittent basis.
SED Definition for Health Home - DSM Qualifying Mental Health Categories*
Anxiety Disorders
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*Any diagnosis in these categories can be used when evaluating a child for SED. However, any diagnosis that is secondary to another medical condition is excluded.
Functional Limitations Requirements for SED Definition of Health Home -The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas as determined by a licensed mental health professional:
- Ability to care for self (e.g. personal hygiene; obtaining and eating food; dressing; avoiding injuries); or
- Family life (e.g. capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or
- Social relationships (e.g. establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or
- Self-direction/self-control (e.g. ability to sustain focused attention for a long enough period of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability); or
- Ability to learn (e.g. school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school.
