new text begin Behavioral health home service delivery standards. new text end

new text begin (a) A behavioral health home services provider must meet the following service delivery standards: new text end

new text begin (1) establish and maintain processes to support the coordination of an individual's primary care, behavioral health, and dental care; new text end

new text begin (2) maintain a team-based model of care, including regular coordination and communication between behavioral health home services team members; new text end

new text begin (3) use evidence-based practices that recognize and are tailored to the medical, social, economic, behavioral health, functional impairment, cultural, and environmental factors affecting the individual's health and health care choices; new text end

new text begin (4) use person-centered planning practices to ensure the individual's health action plan accurately reflects the individual's preferences, goals, resources, and optimal outcomes for the individual and the individual's identified supports; new text end

new text begin (5) use the patient registry to identify individuals and population subgroups requiring specific levels or types of care and provide or refer the individual to needed treatment, intervention, or services; new text end

new text begin (6) utilize the Department of Human Services Partner Portal to identify past and current treatment or services and identify potential gaps in care; new text end

new text begin (7) deliver services consistent with the standards for frequency and face-to-face contact required by the commissioner; new text end

new text begin (8) ensure that a diagnostic assessment is completed for each individual receiving behavioral health home services within six months of the start of behavioral health home services; new text end

new text begin (9) deliver services in locations and settings that meet the needs of the individual; new text end

new text begin (10) provide a central point of contact to ensure that individuals and the individual's identified supports can successfully navigate the array of services that impact the individual's health and well-being; new text end

new text begin (11) have capacity to assess an individual's readiness for change and the individual's capacity to integrate new health care or community supports into the individual's life; new text end

new text begin (12) offer or facilitate the provision of wellness and prevention education on evidenced-based curriculums specific to the prevention and management of common chronic conditions; new text end

new text begin (13) help an individual set up and prepare for medical, behavioral health, social service, or community support appointments, including accompanying the individual to appointments as appropriate, and providing follow-up with the individual after these appointments; new text end

new text begin (14) offer or facilitate the provision of health coaching related to chronic disease management and how to navigate complex systems of care to the individual, the individual's family, and identified supports; new text end

new text begin (15) connect an individual, the individual's family, and identified supports to appropriate support services that help the individual overcome access or service barriers, increase self-sufficiency skills, and improve overall health; new text end

new text begin (16) provide effective referrals and timely access to services; and new text end

new text begin (17) establish a continuous quality improvement process for providing behavioral health home services. new text end

new text begin (b) The behavioral health home services provider must also create a plan, in partnership with the individual and the individual's identified supports, to support the individual after discharge from a hospital, residential treatment program, or other setting. The plan must include protocols for: new text end

new text begin (1) maintaining contact between the behavioral health home services team member, the individual, and the individual's identified supports during and after discharge; new text end

new text begin (2) linking the individual to new resources as needed; new text end

new text begin (3) reestablishing the individual's existing services and community and social supports; and new text end

new text begin (4) following up with appropriate entities to transfer or obtain the individual's service records as necessary for continued care. new text end

new text begin (c) If the individual is enrolled in a managed care plan, a behavioral health home services provider must: new text end

new text begin (1) notify the behavioral health home services contact designated by the managed care plan within 30 days of when the individual begins behavioral health home services; and new text end

new text begin (2) adhere to the managed care plan communication and coordination requirements described in the behavioral health home services manual. new text end

new text begin (d) Before terminating behavioral health home services, the behavioral health home services provider must: new text end

new text begin (1) provide a 60-day notice of termination of behavioral health home services to all individuals receiving behavioral health home services, the commissioner, and managed care plans, if applicable; and new text end

new text begin (2) refer individuals receiving behavioral health home services to a new behavioral health home services provider. new text end