Policy Title: Continuity of Care and Re-engagement for Enrolled Health Home Members Policy HH0006

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Policy Title: Continuity of Care and Re-engagement for Enrolled Health Home Members Policy number: HH0006
Effective date: October 1, 2017
Last revised: March 4, 2019

Applicable to: This policy pertains to adults and children enrolled in the Health Home Program

Purpose
The role of the Health Home care manager (CM) is to provide access to services and coordinate the care and services provided to Health Home members to maximize health and support the member in reaching goals. In the presence of Health Home consent, a care team is created consisting of the member, care manager, Medicaid Managed Care Plan (MMCP), care and service providers, collaterals and others approved by the member who communicate with one another to assure member's needs are addressed in a comprehensive manner. Keeping members engaged in care management services is vital to this process. However, CMs are faced with members who become disengaged and must therefore respond appropriately and timely to locate and re-engage these members.

This policy provides guidance to Health Homes (HH) regarding measures that must be taken to locate and re-engage enrolled members upon determining that continuity of care management services has been disrupted, and to prevent the potential for future disengagement.

This policy replaces any information provided in Medicaid updates and guidance webinars posted on the Health Home website related to this subject matter, issued prior to the effective date of this policy, as well as the following policy and procedures found in the Health Homes Provider Manual - Billing Policy and Guidance, Version 2014-1:

• Under Section III: Claims Submission and Billing for Health Home Services
  3.7 Payment for Health Home Members During an Extended Inpatient Stay
  3.8 Health Home Member Lost to Services, Outreach for Re-engagement, or Disenrollment

Scope
When a member's continuity of care is disrupted, the care management agency must initiate appropriate activities intended to more effectively locate disengaged members which, at minimum, will include involvement of the member's care team (e.g., member, CMA, CMA Supervisor, member's MMCP, HH, family supports (including parent, guardian, legally authorized representative, and others approved by the member).

References
The following Health Home policies and procedures are referenced within this policy and must be followed to support procedures as identified:

• Disenrollment from the Health Home Program policy
• Health Home Notice of Determination and Fair Hearing Process policy
• Health Home Quality Management Program policy

Definitions

The following definitions are provided as guidance when conducting activities to locate, re- engage, and retain HH enrolled members, and outlines the responsibilities of the CM/CMA and others in the process.

Billing.
Depending on circumstances related to member location and re-engagement activities, certain Billing rules apply, must be followed, and are described within this policy. Supporting documentation must be in place showing evidence of CM activities related to search efforts, member re-engagement, retention, and disenrollment.

Reminder: If a CM does not provide the minimum core services required for billing in a given month, then the CM must respond 'no' to the question 'Was a core Health Home service provided this month' in the monthly billing questionnaire. No billing is allowed for that month.

Critical Time Intervention (CTI).
CTI is a time-limited evidence-based practice that focuses on building a support network for members during a period of transition into the community from an excluded setting, or in preparation for disenrollment from the HH program. A CTI plan aids in community integration and continuity of care by helping the member to establish a stable system of community supports. CTI happens over a period of time to allow for observation of the member's support network and progress toward becoming more self-reliant to support a successful and long-lasting transition. Health Homes should include in policy the use of CTI to maintain retention and prevent disengagement of HH enrolled members, and to support successful disenrollment.

Diligent Search Efforts.
As soon as a member is determined to be disengaged from care management services, efforts to locate and re-engage the member must be intensified beyond Standard CM activities (refer to Definition for Standard CM activities). Diligent Search Efforts are permitted for a period of up to three consecutive months*, determined by the CMA (*refer to instructions for Health Homes Serving Children (HHSC) on the following page) beginning the month in which the member is deemed disengaged from CM services, and must be managed by the CMA/CM as follows:

1. a minimum of three or more activities must be conducted during each month to locate and re-engage the member. Activities must be progressive in nature and vary to ensure all opportunities to locate members are exhausted;
2. in Month One, the CM must inform both the member's MMCP and HH collectively of the member's disengagement (this is considered one of three or more required activities);
3. additional Diligent Search Effort activities include, but are not limited to:
   • attempting face-to-face visit to the last known address;
   • phone contact with care and service providers;
   • contacting Local Government Unit (LGU)/Single Point of Access (SPOA);
   • contacting collaterals, emergency contacts and supports to include parent, guardian or legally authorized representative, family, etc.;
   • contacting the member's Parole Officer or Probation Officer, if applicable;
   • accessing online criminal justice resources (e.g., WebCrim);
   • contacting schools;
   • contacting Methadone clinic;
   • reviewing hospital alerts, RHIO, and PSYCKES; and,
   • others, appropriate to the member and to support search efforts.
   NOTE: If CMA/CM did not perform Diligent Search Efforts during any of the three consecutive months, then Billing cannot occur for that month(s).
4. if Diligent Search Efforts do not result in the location of the member, the member must be disenrolled from the HH program (refer to Section F. Member cannot be located).

*Health Homes Serving Children (HHSC):
If the child/youth is contacted, then the child/youth should not be considered disengaged. Special rules apply for performing Diligent Search Efforts activities for a child/youth enrolled in a HHSC based on whether the child/youth is able to self- consent, as follows:

For a child or youth unable to self-consent:
For child/youth unable to self-consent, regardless of acuity, the CMA/CM will have up to three months of Diligent Search Efforts, which will require a face-to-face contact as one of the three required activities. If the child/youth cannot be contacted due to disengagement from CM services, then within the first month of Diligent Search Efforts a face-to-face meeting with the parent, guardian or legally authorized representative is required to ascertain their knowledge of the location for the child/youth and what steps have been taken to locate the child/youth (i.e. child has run away and a missing persons police report has been made). The parent, guardian or legally authorized representative must agree (as consenter for the child's HH enrollment) to notify the CM when and if the child is located, at which time the CM must reengage the child/youth.

If the first month of Diligent Search Efforts does not result in locating the child/youth, the CMA/CM may use the two remaining months to continue Diligent Search Efforts. However, in order for the CMA to bill for activities related to Diligent Search Efforts, a face-to-face contact with different involved relevant family member(s), friends, supports and professionals who are consented for and are part of the care team, must be conducted. If during the two remaining months a face-to-face contact does not occur, the CMA cannot bill for that month.

If the three months of Diligent Search Efforts do not result in locating/reengagement of the child/youth, then the CMA/CM must disenroll the child/youth.

For child/youth who self-consents:
For child/youth who is able to self-consent regardless of acuity, the CMA/CM will have up to three months of Diligent Search Efforts which will require a face-to-face contact each month as one of the three required activities. If the child/youth cannot be contacted due to disengagement from CM services, then the required face-to-face meeting must occur with the parent or guardian, if involved, and/or a face-to-face contact with involved relevant family member(s), friends, supports and professionals who the member had consented for and are part of the care team. The CM must ascertain their knowledge of the location for the child/youth and agreement to notify the CM when and if the child is located, at which time the CM must reengage the child/youth. Each month, the face-to-face requirement needs to be with a different involved relevant consented/care team individual. If Diligent Search Efforts do not result in locating/engagement of the child/youth, then s/he must be disenrolled.

Disengaged.
A member may be deemed disengaged from CM services when Standard CM activities have been attempted but do not result in successful contact with the member. Before determining a member as disengaged from CM services, the CM should take into account usual patterns of behavior exhibited by the member known to result in inconsistent engagement or anticipated temporary disengagement (such as: a pattern of inconsistent attendance with scheduled appointments despite CM reminders; member is without stable housing and changes living arrangements frequently; member is often without access to a phone; youth who continually run away, etc.).

NOTE FOR HHSC: Each time the child/youth is missing, runs away, or the CM is unable to conduct a face-to-face contact does not necessarily mean the individual is truly disengaged from HH care management services, and therefore, the CMA/CM must ensure appropriate steps are taken before beginning Diligent Search Efforts.

Excluded Settings.
For the purpose of this policy, 'excluded settings' are defined as: inpatient, hospitalization, or residential facility; incarceration; nursing home, etc.

This also includes a psychiatric center in relation to individuals who are between 21 and 64 years of age and residing in the center.

Member Status.
A member's engagement status may require changes in the MAPP HHTS during the course of search and re-engagement efforts based on CM activities as specified in this policy.

Standard Care Management Activities.
Standard CM activities may include, but are not limited to: face-to-face visits, interactive communications via phone calls and/or electronic communications, direct contact with care team members, family/supports including parent, guardian, legally authorized representative, other collaterals, and so forth.

NOTE: Activities such as leaving a voice message, mailing a letter, and sending texts or emails are necessary activities to keep a member engaged in care management. However, if these methods do not result in a reply from the member, they cannot be considered CM core services.

Procedures
To meet the needs of any given member in a fully integrated person-centered care model, the CM must be able to engage with members and provide core Health Home services on a consistent basis. When engagement with the member does not occur, the CM needs to determine an appropriate course of action to take to locate and re-engage the member, for example: what steps will be taken? for how long?

The CM must determine when the member is deemed disengaged from CM services, and initiate more intensive efforts to locate the member, as defined in this policy.

HHs must establish and maintain policies and procedures that address how a member is identified as disengaged from care management services; steps that must be taken to search for and re-engage disengaged members; specific timeframes associated with location and re-engagement efforts; acceptable billing practices; and quality monitoring activities.

HH policies and procedures must include, but are not limited to the following:

A. Initiating Location and Re-engagement Activities (Diligent Search Efforts).
Upon first identifying a member as disengaged from CM services, the CM must initiate
Diligent Search Efforts (refer to Definition), to include the following:

1. document all efforts taken to engage the member through Standard Care Coordination Activities and how the member was identified as disengaged from CM services.
2. notify the CM supervisor of member's disengagement and discuss the plan for conducting Diligent Search Efforts. (refer to Section G of this policy: The Role of the CMA Supervisor).
3. document all Diligent Search Efforts taken to locate the member, including notification to the MMCP and/or HH, and the outcome of all activities.
4. Member Status. During the period of Diligent Search Efforts, the member's enrollment segment in the MAPP HHTS must be in the "pended' status with a pend reason code of 05, "Pended due to Diligent Search Efforts."
5. Billing. Billing at the enrollment rate is allowed during the three months of Diligent Search Efforts, as long as the CMA can demonstrate that appropriate search efforts were conducted (refer to Definitions section for special rules related to HHSC).

B. Successful member location and re-engagement.
Upon successful location of the member, the CM must assure timely re-engagement occurs.

The CM must:

1. discuss with the member any reasons for disruption in continuity of care and possible resolution;
2. ensure all consents are still active and in place, or seek proper consents or make needed updates;
3. discuss with member's care team any issues identified to collaborate on possible ways to prevent reoccurrence and support member retention and safety;
4. evaluate and screen the member for additional risk factors, and complete appropriate assessments, as indicated;
   • For Health Homes Serving Children: refer to guidance on completing CANS-NY and conducting an interdisciplinary team meeting in the face of a significant life event.
5. update the member's plan of care if any changes are identified in member goals or service needs, and notify the member's care team;
6. conduct a case review with the CM supervisor and/or care team, as appropriate.
7. Member status. The CMA must create a new enrollment segment in the MAPP HHTS for the member, backdated to the first day of the month in which the member was located.
8. Billing. The CMA may resume billing at the enrollment rate for activities conducted to locate and re-engage the member.

C. When the member is located within an excluded setting.
There may be instances when a member is located in an "excluded setting" (refer to Definition) and, therefore re-engagement of the member may not occur immediately.

If the CM anticipates that the member will be in the excluded setting for more than six (6) months, then the CM should end date the member's segment with the appropriate end date reason code. The CM must follow procedures for disenrolling the member from the HH program.

Additional requirements can be found in the following policies:

• refer to: Disenrollment from the Health Home Program policy
• refer to: Health Home Notice of Determination and Fair Hearing Process policy

If the CM anticipates that a member will be in an excluded setting for less than six (6) months, then the member can remain enrolled in the Health Home program in pended status for a period of six consecutive months to support member retention and opportunities for re-engagement. Use the following definitions to calculate the six (6) months.

For members located in an inpatient facility or nursing home, the six-month period begins on the date of admission into that setting.

For incarceration, the six-month period is calculated beginning on the first day of incarceration.

For members expected to be discharged/released from the excluded setting within six (6) months of their admission date, a warm handoff/direct linkage to CM services is vital to support the safe transition and timely re-engagement of the member. The CM/CMA should prepare for the member's discharge/release by monitoring the member's status to assure participation in discharge planning procedures occurs.

To establish the likelihood of the member's discharge/release from an excluded setting within the six-month period, the CM must:

1. make contact with the member and/or discharge planning staff of excluded setting to provide notification of the member's HH enrollment, confirm the member's admission/incarceration date and anticipated length of stay in the excluded setting, and to collaborate on discharge planning procedures; NOTE: Upon identifying an enrolled member as incarcerated, the HHCM must contact the criminal justice setting to ascertain the length of anticipated sentence (less/greater than six months). Although this is not a billable HHCM activity, it is necessary to support the member's HH enrollment and continuity of care upon release (refer to the Member Status and Billing section of this policy).
2. document all communication(s) with the member and/or discharge planning staff, and outcomes, including potential for member's disenrollment from the HH program;
3. review outcomes with CM supervisor and establish plan for member re- engagement, or member disenrollment, if indicated;
4. notify the member's care team; and;
5. update member's plan of care accordingly.

Member Status and Billing.
When a member is in an excluded setting, certain protocols apply related to the Member's Status in the MAPP HHTS and billing activities, as follows:

1. Making direct contact with the member and/or discharge planning staff of the excluded setting may be considered a core CM service as long as the CM can demonstrate proper contact was made for the purpose of the member's discharge/release from the excluded setting.
   
   For the month in which the member enters the excluded setting, or the CM/CMA first makes contact with the member and/or staff of the excluded setting, the CMA may bill for CM services at the enrollment rate. The CMA must change the member's enrollment segment status to 'active' for this one month, resuming 'pended' status for subsequent months during which time billing may not occur.
   
   For incarceration. If the HHCM performs a core service within the same month the member was incarcerated (e.g. conducts appropriate Diligent Search Efforts), the CMA can bill as long as the core service was provided PRIOR TO the date of incarceration. Any core service provided ON/AFTER the date of incarceration may not be billed for, and no billing is allowed for the remainder of the time the member is incarcerated.
   
   The member's segment in the MAPP HHTS should be pended on the first day of the month immediately following the month in which the member was incarcerated.
2. During the period of time when the member is in the excluded setting, the member's segment in the MAPP HHTS must be in 'pended' status with the appropriate pend reason code. If an existing pend reason code does not adequately describe the excluded setting, the segment should be pended using pend reason code 04, "Pended due to Other" with a comment of "Excluded Setting" and specifying the type of setting.
3. In the thirty (30) days prior to the member's discharge from the excluded setting, if the CM/CMA participates in active discharge planning activities to re-engage the member, the member's enrollment segment must be changed to 'active' status and the CMA may bill for this month (this does not apply to members who are incarcerated).
4. Upon the member's discharge/release with successful re-engagement the CMA may maintain the member's 'active' enrollment status, and resume billing activities.

NOTE: This policy provides standards of practice for locating and re-engaging members. CMs must use professional discretion when identifying opportunities to re- engage members whose discharge/release may require a period slightly longer than six months.

D. Member requests to disenroll from Health Home Program.
A member may ask to disenroll from the Health Home program at any time. If this should occur during re-engagement activities, the CM must:

1. evaluate the current state of the member and inquire whether the member's decision to disenroll is related to a complaint or dissatisfaction with an aspect(s) of the HH program. Provide follow up as appropriate;
2. provide critical time intervention accordingly;
3. follow procedures for a timely and safe disenrollment plan found in the following HH policy:
   • refer to: Disenrollment from the Health Home Program policy
4. Member status. The CMA must end the member's enrollment segment with the last day of the month in which the member disenrolls using the most appropriate Segment End Date Reason Code.
5. Billing. Upon disenrollment of the member, all billing must cease.
   If a core service is provided in the month of disenrollment, billing can occur during that month (e.g., member receives services on 6/15, then withdraws consent on 6/22).

E. Member cannot be located.
If after Diligent Search Efforts have been conducted the member is not located, the member must be disenrolled from the Health Home program.
The CM must:

1. follow procedures for disenrollment from the HH program found in the following HH policies:
   • refer to: Disenrollment from the Health Home Program policy
   • refer to: Health Home Notice of Determination and Fair Hearing Process
2. Member status. The CMA must end the member's enrollment segment using the most appropriate Segment End Date Reason Code (e.g. reason code #14 Enrolled Health Home member disengaged from Care Management services).
3. Billing. Upon disenrollment of the member, all billing must cease.

F. The Role of the CMA Supervisor.
The role of the CM supervisor is vital to ensuring appropriate activities were taken to locate and re-engage members determined to be disengaged from CM services.

The CM supervisor must:

1. ensure that the CM notifies their supervisor whenever a member is determined to be disengaged from care management services;
2. provide CMs with clinical and policy guidance to support all level of search efforts;
3. be actively involved in the decision to disenroll the member from the HH program;
4. participate in case reviews, as appropriate;
5. assure notification is provided to MMCP, and,
6. assure timely notification to HH occurs for the provision of Notice of Determination, where applicable.
   Additional requirements can be found:
   • refer to: Disenrollment from the Health Home Program policy
   • refer to: Health Home Notice of Determination and Fair Hearing Process policy

G. Quality Monitoring.

HHs must evaluate patterns related to member disengagement within its own network and establish Quality Monitoring activities to address issues identified.

HH must assure quality monitoring activities are in place and include:

• reasons for member disengagement using the lens of avoidable versus unavoidable events;
• appropriateness of care management efforts used to locate, reengage and retain members;
• timelines were followed and met;
• maintenance of Member Status;
• billing procedures were followed;
• involvement of CMA Supervisor;
• update to the member plan of care in response to changes in service needs or identified risk factors, as needed;
• timely notification to MMCP and HH;
• appropriate notification to member's care team;
• members not located;
• members that could not be re-engaged in CM services (e.g., excluded setting longer than six month);
• members disenrolled from HH program; and,
• appropriate training is provided to HH and CMA staff in response to outcomes from quality monitoring activities.