Sec. 10.09.33.07. Health Home Participant Flow

A. Enrollment.

(1) The health home shall enroll an individual only after the individual has been enrolled in the health home provider’s applicable PRP, MTS, or OTP services.

(2) An OTP established as a health home shall identify eligible individuals under the OTP's care and report the qualifying risk factors diagnoses through eMedicaid during enrollment.

(3) The health home shall provide the individual with a brief description of health home services, including:

(a) Explaining the data-sharing elements of the program; and

(b) Describing how the individual may opt out if desired.

(4) Following the provision of information in accordance with §A(3) of this regulation, the health home shall obtain the individual’s consent to participate in the health home.

(5) Following consent to participate in accordance with §A(4) of this regulation, the health home shall complete the individual’s online eMedicaid intake report thereby enrolling the individual into the health home.

(6) The health home shall:

(a) Notify a participant's other treatment providers about health home services; and

(b) Encourage other providers’ participation in care coordination efforts.

B. Participation.

(1) A health home participant shall receive a minimum of two health home services per month, as defined in eMedicaid and to be documented in eMedicaid.

(2) An assigned health home care manager shall monitor the participant’s care and health status and coordinate with other staff to provide appropriate health home services.

C. Discharge.

(1) In the event of discharge, the health home shall create a discharge plan that includes referrals to appropriate services and providers.

(2) The health home shall report all discharges and completion of discharge plans in eMedicaid.