Assessment, Process and Quality Metrics


The following documents represent the versions of the FACT-GP and the Health Home Functional Assessment that are to be used on each Health Home at enrollment, annually and at discharge. These do not take the place of the comprehensive assessment that should be done on each enrollee. They do allow the department to collect basic information about the members in the health home in order to adjust risk scoring and to measure longitudinal changes in this population.

The required languages are provided in both instruments. Instructions are included to explain the scoring of the tool. One can either do one's own scoring or can use a scoring sheet that automatically scores the tools. The department recommends use of the latter scoring sheet to reduce mathematical errors. The results of these instruments will be reported on the Health Home CMART which will be posted shortly.


*Please note: There are two Chinese versions of the FACT-GP and Health Home Functional Assessment – Simplified (MCHI) and Traditional (TCHI). The Simplified version is used in China, Malaysia and Singapore, and the Traditional version is used in Hong Kong and Taiwan. Users should ask respondents which version they would prefer.

Health Home Functional Questionnaire

Scoring for the FACT - GP and Health Home Functional Questionnaire

FACT - GP and Health Home Questionnaire Scoring Sheet

Quality Measures

Process Measures (HH-CMART)

The Health Home Care Management Assessment Reporting Tool (HH-CMART) is a tool for the collection of standardized care management data for members assigned to Health Homes. The data will provide the Department of Health (DOH) with information about care management services to evaluate the volume and type of interventions and the impact care management services have on outcomes for people receiving these services. The data requirements include submission of specified data about care management services provided to members in Health Homes. The submission file will include information for all Medicaid members involved in Health Home care management programs during the reporting period.

The Department will be conducting regular technical support webinar / call sessions geared toward supporting the technical aspects of collecting care management data using the HH-CMART. For any questions on the HH CMART documents can be directed to the Health Home email box using the web form located: Email NYS Health Homes Program