Transition from Targeted Case Management (TCM) to Health Home Care Management and non-medicaid funded Care Management (CM)

Transcription

1 Transition from Targeted Case Management (TCM) to Health Home Care Management and non-medicaid funded Care Management (CM) Interim Instruction: February 21, 2012 The New York State (NYS) Office of Mental Health s (OMH) TCM program serving adults will transition to Health Home Care Management (as each phase of Health Home (HH) implementation is implemented by the NYS Department of Health (DOH). The care management within HHs can be provided by transitioning TCM programs or other programs that contract with the HH. The following guidance is being provided by OMH to assist TCM programs and their existing resources in its transition to HHs: Care management will have a different focus than TCM Health Homes are designed to help people manage chronic health conditions to improve health outcomes and reduce the use of inappropriate inpatient and emergency room care. The care management funded through Health Homes will assess the individual person s physical, mental health, substance use, and social services needs. An integrated plan of care will be developed and care managers will help the individual manage this plan of care by accessing appropriate services in the various systems of care, facilitate communication across health care providers, and assist the person in following the plan of care. This will require some TCM workforce retraining and expanded knowledge of physical health services. Some Medicaid members assisted during the first wave to Health Homes will have significant behavior health conditions, many also having co-occurring chronic physical health illnesses. A high percentage of this initial group will be unengaged in ambulatory care and have high usage of services in inpatient and emergency room settings. Former TCM services, one of the most intensive levels of care management, will be a critical resource in helping Health Homes to assist these individuals in improving their health outcomes. To make the former TCM resource available to those most in need at critical points in their care, the OMH will expect an increased flow of individuals with serious mental illness through the former TCM slots. This can be accomplished because the former TCM resource will now be embedded in a Health Home so people can be stepped down, as needed, to lower intensity care management creating increased availability of high intensity CM slots. With increased availability of high intensity CM slots people will be able to benefit from rapid engagement with the care manager at the critical points in transition from inpatient to outpatient (critical time intervention). They will also benefit from intensive care management to help with engagement in appropriate ambulatory care and social service supports, reducing reliance on emergency and inpatient use and improving health outcomes. The successful use of the former TCM resource and the flow of people through CM will require close collaboration among the Health Home, TCM services, the County, the managed care plans, and the State. Shifting from the Targeted Case Management option to Care Management: The TCM model of care in OMH focused on the plan of care for an individual s mental health barriers. The model worked within a system that was built around silos of services that did not require case managers to become expert in other systems of care. A working knowledge of other care systems was beneficial but was not within the primary scope of duties for a TCM. The TCM model never was conceived to be one that integrated care as its primary function. 1

2 With the advent of the HH there is a need to conceive anew what a plan of care includes. Former care managers (CMs) will have a pivotal role in creating integrated plans of care. Integrated planning requires CMs to understand multiple systems of care. This shift will require the support of the State, local government, hospitals and the community-based provider system to be successful. The CMs will need to build and refine their: Outreach and engagement skills, motivational interviewing skills and skills to create recipient-centered and strength-based plans of care, knowledge of the physical health care system and the substance abuse disorder care system, awareness of evidence-based practices and best practices and be able to identify quality providers, such as; integrated dual disorder treatment, individual placement and support, wellness self-management, family education, assertive community treatment, critical time intervention, and medication management, access to the social services system and how to access resources and stay up to date with changing rules regarding benefits and entitlements, housing, employment supports, transportation, self-help groups, all of which may be essential to an individual and their recovery. OMH expects that the local government unit (LGU) will contract with former TCM providers for the state aid for service dollars and to serve people who are not Medicaid enrolled. A contract between the LGU and a CM provider will enable an agency to bill for the former (or legacy) TCM slots in the HH model. Without this contract the Health Home OMH/TCM rate code (this will be the rate code designated for the former TCM slots a TCM program was paid for on average each month, please see Reimbursement for individuals assigned to a CM) will not be available to CM programs. The contract between the LGU and the CM program may be useful as part of the process to maintain quality control for the practice of care management. In addition, the LGU must work closely with managed care plans, health homes, and former TCM providers, and the State as part of the process to monitor the quality of this care management. Assignment of Individuals from Former TCM Slots Who Are Medicaid Eligible: Upon implementation of HHs, all current TCM enrollees who are Medicaid eligible will be assigned to a HH by the TCM provider. The TCM will make this assignment based on the HHs the TCM is participating with and the information the TCM has about the enrollees to make an appropriate assignment. The CM program will explain and work to secure the enrollees consent in the HH program and to allow patient information to be shared. After implementation, the LGU will decide how single point of access (SPOA) process and the HH will work together to assign other Medicaid eligible individuals to the former TCM slots. Please see section on SPOA for guidance on the SPOA process and HHs. Assignment of Individuals Who Are Non-Medicaid Eligible to Care Management: Former TCM programs are expected to serve all non-medicaid individuals who are being served by the TCM program at the time of HH implementation as a CM provider. After implementation, the SPOA process will continue to assign individuals in need of care management who are not Medicaid eligible to CM providers. Please see section on SPOA for guidance on the SPOA process and HHs. 2

3 Health Home Services: Section 1945(h)(4) of the Affordable Care Act defines health home services as comprehensive and timely high quality services, and includes the following health home services to be provided by designated health home providers or health teams: Comprehensive care management; Care coordination and health promotion; Comprehensive transitional care from inpatient to other settings, including appropriate follow-up; Individual and family support, which includes authorized representatives; Referral to community and social support services, if relevant; and The use of health information technology to link services, as feasible and appropriate. The following definitions are from the State Plan Amendment (SPA) submitted recently approved by CMS entitled Health Homes for Individuals with Chronic Conditions. Each definition includes health information technology (HIT) expectations that are not included here but may be found on the DOH website: Comprehensive Care Management: A comprehensive individualized patient centered care plan will be required for all health home enrollees. The care plan will be developed based on the information obtained from a comprehensive health risk assessment used to identify the enrollee s physical, mental health, chemical dependency and social service needs. The individualized care plan will be required to include and integrate the individual s medical and behavioral health services, rehabilitative, long term care, social service needs, as applicable. The care plan will be required to clearly identify the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), care manager and other providers directly involved in the individual s care. The individual s plan of care must also identify community networks and supports that will be utilized to address their needs. Goals and timeframes for improving the patient s health, their overall health care status and the interventions that will produce this effect must also be included in the plan of care. The care manager will be required to make sure that the individual (or their guardian) plays a central and active part in the development and execution of their plan of care, and that they are in agreement with the goals, interventions and time frames contained in the plan. Family members and other supports involved in the patient s care should be identified and included in the plan and execution of care as requested by the individual. The care plan must also include outreach and engagement activities which will support engaging the patient in their own care and promote continuity of care. In addition, the plan of care will include periodic reassessment of the individual s needs and goals and clearly identify the patient s progress in meeting goals. Changes in the plan of care will be made based on changes in patient need. Care Coordination: The health home provider will be accountable for engaging and retaining health home enrollees in care, as well as coordinating and arranging for the provision of services, supporting 3

4 adherence to treatment recommendations, and monitoring and evaluating the enrollee s needs. The individualized plan of care will identify all the services necessary to meet goals needed for care management of the enrollee such as prevention, wellness, medical treatment by specialists and behavioral health providers, transition of care from provider to provider, and social and community services where appropriate. In order to fulfill the care coordination requirements, the health home provider will assign each individual enrollee one dedicated care manager who is responsible for overall management of the enrollee s plan of care. The enrollee s health home care manager will be clearly identified in the patient record and will have overall responsibility and accountability for coordinating all aspects of the individual s care. The health home provider will be responsible to assure that communication will be fostered between the dedicated care manager and treating clinicians to discuss as needed enrollee s care needs, conflicting treatments, change in condition, etc. which may necessitate treatment change (i.e., written orders and/or prescriptions). The health home provider will be required to develop and have policies, procedures and accountabilities (contractual agreements) in place, to support and define the roles and responsibilities for effective collaboration between primary care, specialist, behavioral health providers and community-based organizations. The health home providers policies and procedures will direct and incorporate successful collaboration through use of evidence-based referrals, follow-up consultations, and regular, scheduled case review meetings with all members of the interdisciplinary team. The health home provider will have the option of utilizing technology conferencing tools including audio, video and /or web deployed solutions when security protocols and precautions are in place to protect PHI to support care management/coordination activities. The health home provider will be required to develop and utilize a system to track and share patient information and care needs across providers, monitor patient outcomes, and initiate changes in care as necessary to address patient need. Health Promotion Service Definition Health promotion begins for eligible health home enrollees with the commencement of outreach and engagement activities. NYS health home plan for outreach and engagement will require a health home provider to actively seek to engage patients in care by phone, letter, HIT and community in reach and outreach. Each of these outreach and engagement functions will all include aspects of comprehensive care management, care coordination, and referral to community and social support services. All of the activities are built around the notion of linkages to care that address all of the clinical and non-clinical care needs of an individual and health promotion. The health home provider will support continuity of care and health promotion through the development of a treatment relationship with the individual and the interdisciplinary team of providers. The health home provider will promote evidence based wellness and prevention by linking health home enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self- help recovery resources, and other services based on individual needs and preferences. Health promotion activities will be utilized to promote patient education and self management of their chronic condition(s). Comprehensive Transitional Care (including appropriate follow-up, from inpatient to other settings) Service Definition Comprehensive transitional care will be provided to prevent enrollee avoidable readmission after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing or 4

5 treatment facility) and to ensure proper and timely follow up care. To accomplish this, the health home provider will be required to develop and have a system in place with hospitals and residential/rehabilitation facilities in their network to provide the health home care manager prompt notification of an enrollee s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting. The health home provider will also have policies and procedures in place with local practitioners, health facilities including emergency rooms, hospitals, and residential/rehabilitation settings, providers and community-based services to ensure coordinated, and safe transition in care for its patients who require transfer to/from sites of care. The health home provider will be required to develop and have a systematic follow-up protocol in place to assure timely access to follow-up care post discharge that includes at a minimum receipt of a summary care record from the discharging entity, medication reconciliation, and a plan for timely scheduled appointments at recommended outpatient providers. The health home care manager will be an active participant in all phases of care transition: including: discharge planning and follow-up to assure that enrollees received follow up care and services and re-engagement of patients who have become lost to care. Individual and Family Support Services (including authorized representatives) Service Definition The patient s individualized plan of care will reflect and incorporate the patient and family or caregiver preferences, education and support for self-management; self help recovery, and other resources as appropriate. The provider will share and make assessable to the enrollee, their families or other caregivers (based on the individual s preferences), the individualized plan of care by presenting options for accessing the enrollee s clinical information. Peer supports, support groups, and self-care programs will be utilized by the health home provider to increase patients and caregivers knowledge about the individual s disease(s), promote the enrollee s engagement and self management capabilities, and help the enrollee improve adherence to their prescribed treatment. The provider will discuss and provide the enrollee, the enrollee s family and care givers, information on advance directives in order to allow them to make informed end-of-life decisions ahead of time. The health home provider will ensure that all communication and information shared with the enrollee, the enrollee s family and caregivers is language, literacy and culturally appropriate so it can be understood. Referral to Community and Social Support Services Service Definition The health home provider will identify available community-based resources and actively manage appropriate referrals, access to care, engagement with other community and social supports, coordinate services and follow-up post engagement with services. To accomplish this, the health home provider will develop policies, procedures and accountabilities (through contractual agreements) to support effective collaboration with community-based resources, that clearly define the roles and responsibilities of the participants. The plan of care will include community-based and other social support services, appropriate and ancillary healthcare services that address and respond to the patient s needs and preferences, and contribute to achieving the patient s goals. 5

6 Reimbursement for individuals assigned to a CM: OMH currently approves and supports several varieties of TCM (e.g., ICM (Intensive Case Management), SCM (Supportive Case Management) 1:20) each with its own financial model, monthly fee(s)/rate(s), staffing ratio, staffing qualifications, minimum contact expectations, service dollar allocation per slot, and state aid per slot. All new entries to former TCM, now CM, slots are prior authorized by SPOAs, subject to operating agreements between the counties/spoas and HHs. CM will not have discrete program models that parallel historic TCM models (e.g., ICM, SCM). However, there are no prescriptive minimum staff to enrollee ratios for either the basic care management or higher intensity care management services provided by a CM provider (e.g., a former TCM program). Outcomes at every level of CM in a Health Home will be monitored by the CM program and the State and active outreach and engagement or care management must be delivered. Medicaid Reimbursement By definition, individuals who are assigned to HHs will be Medicaid eligible. Upon conversion to HH services the TCM program will no longer bill the TCM rate codes that were used to bill for TCM services. Reimbursement for former (legacy) TCM resources in HHs will be provided via new Medicaid reimbursement and slot allocation methodologies. Definitions: HH OMH/TCM rate a HH rate code that may be billed for a portion (see calculation below) of the slots that were part of the former TCM provider s TCM total slot capacity. This rate has been calculated in an attempt to produce the same annual Medicaid revenue collected by the provider under the former TCM program. HH services rate a HH rate code that may be billed for slots filled with Medicaid enrollees assigned to your CM program in excess of the number of slots authorized to be billed to the HH OMH/TCM rate. This will produce Medicaid revenue in addition to the annual Medicaid revenue previously collected by the provider under TCM. OMH and DOH are calculating HH rates for former OMH TCM providers to attempt to produce the same annual Medicaid revenue as collected by the provider under TCM without change to the individual provider s total authorized TCM slots. The rate calculation for former OMH TCM providers is the total Medicaid revenue collected for all varieties of TCM for the Federal Fiscal Year 2010/11 (October 2011-September 2011), divided by the total number of TCM claims actually paid for the year. (For providers operating less than the full year, the duration used in the calculation is shorter.) The calculation produces a unique monthly HH OMH/TCM rate for each former OMH TCM provider. This rate will only be available up to the number of monthly slots used in this calculation and may be claimed directly through Electronic Medicaid of New York (emedny). The calculated rate for the HH OMH/TCM rate slots will apply to all current TCM enrollees who do not opt out of HH enrollment and for all new assignments into these slots once vacated by an enrollee. For example, a TCM provider has 108 slots that included 48 ICM slots and 60 SCM slots. The provider was paid on average for 75 slots (both ICM and SCM slots) per month. Therefore, the calculated rate will be available only for up to 75 slots each month that may be billed at the HH OMH/TCM rate. 6

7 Reimbursement is available for the difference (33) between the 108 total ICM and SCM slots and the 75 HH OMH/TCM slots. Initially these 33 slots will be already be filled with individuals, some of who may be Medicaid enrollees and others who are not. By agreement between OMH and DOH, subject to the expectations of the LGU regarding slots reserved for non-medicaid enrolled individuals, the remaining 33 slots in this example can be filled by 33 other Medicaid enrollees referred by SPOA (or other local arrangement). The former TCM provider will claim Medicaid directly through emedny for these individuals at the Health Home services rate. The former TCM providers may negotiate with the sponsoring HH, outside of the SPOA process, for additional Medicaid slots at the prevailing HH service rate. If the intensity of need for care management for these slots exceeds the reimbursement provided by the Health Home services rate the former TCM providers may also negotiate for additional payment directly from the HH. There is no limit on the number of HH services rate slots that may be attached to a former TCM provider, subject to agreement with the HH and the LGU which contracts for State Aid and services dollars. These slots will also be claimed by the former TCM program directly through emedny. In the first year after the effective date of the SPA, former TCM providers will receive Medicaid for occupants of the blended rate slots and all HH service rate slots by direct claiming through emedny. The reimbursement plan for succeeding years has not yet been determined. Medicaid claims Individuals replacing current TCM enrollees in the slots that may be billed at the HH OMH/TCM rate will have claims submitted to emedny using two rate codes: 1. The outreach and engagement rate (rate code 1852) will be available for up to three months for individuals referred by the SPOA or HH (by the local process) or may be used to attempt to reengage a TCM enrollee who chooses to opt out of HH enrollment after the former TCM program is converted to CM. This code is used until the person signs the consent agreement, which signals enrollment. The outreach and engagement rate will be equal to the HH OMH/TCM rate. At the conclusion of this three month cycle, outreach and engagement claims are not permitted until another three months have passed. (The number of cycles of outreach and engagement reimbursement, i.e., three months of O &E claims and three months without claims, has not yet been determined.) 2. The HH OMH/TCM rate (rate code 1851) for care management is the HH OMH/TCM rate discussed above for existing TCM enrollees who sign the consent within 3 months of the program s conversion from TCM to HH CM, the existing TCM enrollees who do not sign the consent within 3 months and all new individuals assigned to these slots per the LGU/SPOA-HH agreement. Individuals that are be billed at the HH services rate will have claims submitted to emedny using two rate codes: 1. The outreach and engagement rate (1387) will be available for up to three months for individuals referred by the SPOA or HH (by the local process) or may be used for a transitioning TCM enrollee who chooses to opt out of HH enrollment after the former 7

8 TCM program is converted to CM. This code is used until the person signs the consent agreement, which signals enrollment, up to three months. The outreach and engagement rate will be 80% of the full HH services rate. At the conclusion of this three month cycle, outreach and engagement claims are not permitted until another three months have passed. (It has not been determined the number of cycles that outreach and engagement may be billed by CM.) 2. The HH services rate (1386) care management. The rate code applies to all HH enrolled individuals assigned to the ex-tcm provider other than those claimed to Medicaid using the 1851/1852 rate codes. (The rate paid will be the same as paid to the HH for all other individuals, but only individuals assigned to the ex-tcm provider per the LGU/SPOA-HH agreement and/or the ex-tcm-hh agreement regarding additional slots can be claimed directly to emedny. The Date of Service for all claims will be the first day of the month based on status at the end of the claimed month (i.e., a client who signs a consent on March 28 th will be claimable to emedny with the Date of Service of March 1). The initial claims using any of the rate codes above must be held until the third week of the second month, i.e., in the example above, until about April 20, to allow the WMS registration process to be completed and the initial claim to be paid by emedny. Care managers must provide at least one of the five care management Health Home services (not including the HIT service) per quarter. There must be evidence of activities that support billing, including: Contacts (face-to-face/no required minimum, mail, electronic, telephone) Patient assessment Development of a care management plan Active progress towards achieving goals State Operated TCM, Adult Home Case Management and C&Y TCM The attachment of State Operated TCM programs to HHs will be delayed. The attachment of Adult Home Case Management will also be delayed. These programs are excluded from the unique rate calculations until they are attached to HHs. (These former TCM providers will have their new HH rate recalculated accordingly.) C&Y are NOT part of the pending Health Home SPA. Their future attachment to HHs is not yet determined. Reimbursement for individuals without Medicaid assigned to CM: In addition to the Medicaid enrollees served and reimbursed as described in the previous section the CM program must also continue to serve all of the non-medicaid eligible recipients on their TCM roster at the time of transition from a TCM program to Health Homes. The CM program will be funded via state aid resources, sliding scale fees and third party reimbursement, as appropriate and available. State aid resources will be provided to the LGU in the historic amount. The LGU in their contract with the CM provider may add service standards for these resources. (See Role of LGU ) 8

9 Use of service dollars: Service dollars are financial resources for emergency and non-emergency purposes and are to be used only as payment of last resort. The purpose of the service dollar is to provide funds for recipients immediate and/or emergency needs. The use of service dollars should include participation of the recipient of services, who should play a significant role planning for the appropriateness of the use of this resource, and the actual utilization of, the service dollars resource. Service dollars may only be used for recipients receiving CM services and are assigned to a former TCM slot and for non-medicaid eligible individuals assigned via the LGU/SPOA process. Service dollars may not be used for any other individual who is served by the CM program. Non-emergency use of service dollars are pre-planned and should be indicated in the CM service plan. Emergency use of service dollars are unplanned and so cannot be indicated in the service plan. Any use of service dollars should be noted in the CM record and the recipient must sign for the receipt of the goods or services paid for by service dollars. Agency administrative expenses cannot be allocated from these funds. Health Home CM and Assisted Outpatient Treatment: Health Homes and their CM programs will be serving people who have been assigned by the courts to assisted outpatient treatment status. The HH and their CM programs must be aware of MHL Section 9.60, Assisted Outpatient Treatment, including all reporting requirements detailed in the law and by the LGU. A judge may prescribe in an individual s AOT orders the participation in a HH in order to receive CM services. The Role of the State Agencies The state agencies are designating, not licensing HHs. Similarly, the State is providing guidance and not issuing regulations for its governance of HHs at this time. The relationship between the HH lead and members of the HH network, including the former TCM providers, will be indicated by the subcontract(s) with the HH and members of the HH network. DOH will provide CMs and HHs guidance regarding documentation and services to support a Medicaid claim. However, only the HH and the former TCM providers (including OMH TCM, COBRA CM, CIDP, etc.) will receive HH reimbursement either through emedny or from the Medicaid Managed Care Plans (CM providers will bill emedny directly as previously indicated). Therefore, the former TCM providers will have unique responsibility as part of the HH initiative to provide information (including care management metrics and patient functional status information) to the HH lead, the managed care plans and DOH, in addition to the information expectations of the LGU. The Role of OMH OMH is providing this guidance to be followed by CM providers (additional HH billing guidance will be distributed by DOH in a Medicaid Update Article). OMH s information expectations (at this time) are only to submit complete and accurate CFRs (dividing 2011/12 or 2012), as appropriate, between the historical TCM program codes and the new CM program codes. 9

10 Role of the Local Government Unit (LGU)/Single Point of Access (SPOA): Contracting The OMH does not intend to establish program standards for HHs beyond what shall be in the forthcoming State Medicaid Article that will be issued by DOH. The LGU, via their contracting process, are free to establish reasonable standards for these slots that are filled with individuals who are not Medicaid enrollees: Reasonable ratio of staff to intensity level of the number of cases assigned. The qualifications of staff to meet the needs of the cases assigned (i.e., the hiring of peers or RNs) who may not have been hirable under the TCM model because of minimum qualifications or cost of hiring medical professionals. The outcome data to be collected to measure efficacy of the CM programs. Access to the former TCM slots will be jointly managed by the CM program, the County SPOA, the lead HH entity and the managed care plan (if applicable). The LGUs will have, however, substantial authority over the former OMH TCMs programs. All former OMH TCM providers must have a current contract with the LGU to claim the HH OMH/TCM rate or claim the HH services rate through emedny. If the LGU discontinues a contract with a former TCM the former TCM provider will no longer be eligible to claim Medicaid through emedny for the HH OMH/TCM rate slots or the HH services rate slots referred by the HH. The LGU must notify OMH when a contract with a CM provider is terminated and give adequate advance notice of such termination. Role of the Local Government Unit (LGU)/Single Point of Access (SPOA): HH Assignment The LGU will be an important entity that can identify individuals whose treatment histories have not yet qualified them for HH assignment. Some of these individuals may have a recent AOT order, coming from Institutes for Mental Disease, jail or a hospital stay and will be prioritized for care management. For individuals identified by the LGU as immediately needing care management but not on the current HH assignment roster, the LGU will develop a local policy/procedure to identify/qualify these individuals and coordinate with DOH using a referral process for immediate assignment to a HH, if not directly to a former TCM slot. (This process will include the county SPOA contacting the Managed Care Plan for recipients who belong to a plan and the Plan will make a HH assignment. The SPOA will contact DOH for fee-for-service Medicaid recipients. DOH will make the HH assignment.) Eligibility will initially be controlled through sharing of member tracking sheets. Key elements of the tracking sheet (outreach dates, enrollment dates) will be loaded to member eligibility files to support claims and appropriate payment edits. Two options to populate the member tracking sheets will be available initially: manual data entry at the member level or file transfer for all Health Home candidates and participants. System changes are in progress to allow additional functions, e.g., look-up of Health Home status. 10

11 Transitioning TCM providers: Key Considerations Only individuals assigned to former TCM slots will have access to OMH funded service dollars. The former TCM slots must remain assigned to and available only to individuals with serious mental illness (SMI). These resources were provided to serve the community of individuals with SMI who have a high level of CM needs. The LGU/SPOA should expect that CM slots will turnover at a quicker pace than the former TCM program slots have traditionally and close management of the system will allow more people to be better served. In the former TCM program movement out of the program was often delayed or did not occur because of the concern that peoples recovery may be jeopardized when they leave TCM and there were no other similar supports available to them. In HHs people moving from the TCM level will step down to less intensive care management. The LGU/SPOA will also need to keep in mind that the former TCM staff will be asked to expand their level of expertise and coordination to integrate substance use and health care service systems. The integration of these supports is expected to require additional knowledge than the former TCMs may have used in the TCM model. In turn, there will be more freedom for the CM staff than was available in the TCM model program and OMH would expect there will be better access to services and social supports via a health home network. There will be Health Information Technology (HIT) requirements of each HH, the HH network members and most certainly for the care managers serving the high intensity need HH assignees. The LGU/SPOA may need to discuss ways to access data and pertinent information from the HHs in order to better manage the CM system of care in their County. 11