Health Home Serving Children

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Eligibility, Conditions, Appropriateness, and Health Home Six Core Services

Health Home Chronic Condition Eligibility Criteria

  • The individual must be enrolled in Medicaid
  • Medicaid members eligible to be enroll in a Health Home must have:
    • Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*)
    • One single qualifying chronic condition: `
      • ✓ HIV/AIDS (Adults and Children) or
      • ✓ Sickle Cell Disease (Adults and Children) or
      • ✓ Serious Mental Illness (SMI) (Adults) or
      • ✓ Serious Emotional Disturbance (SED) or Complex Trauma (Children)
    • Chronic Condition Criteria is NOT population specific (e.g., being in foster care, under 21, in juvenile justice etc.) does not alone/automatically make a child eligible for Health Home
    • In addition, the Medicaid member must be appropriate for the intensive level of care management services provided by Health Home, i.e., satisfy appropriateness criteria: Eligibility Requirements: Identifying Potential Members for Health Home Services

Complex Trauma Determination Definition
  1. The term complex trauma incorporates at least:
    • Infants/children/or adolescents´ exposure to multiple traumatic events, often of an invasive, interpersonal nature, and
    • The wide-ranging, long-term impact of this exposure.
  2. Nature of the traumatic events:
    • Often is severe and pervasive, such as abuse or profound neglect;
    • Usually begins early in life;
    • Can be disruptive of the child´s development and the formation of a healthy sense of self (with self-regulatory, executive functioning, self-perceptions, etc.);
    • Often occur in the context of the child´s relationship with a caregiver; and v. can interfere with the child´s ability to form a secure attachment bond, which is considered a prerequisite for healthy social-emotional functioning.
  3. Many aspects of a child´s healthy physical and mental development rely on this secure attachment, a primary source of safety and stability.
  4. Wide-ranging, long-term adverse effects can include impairments in:
    • Physiological responses and related neurodevelopment;
    • Emotional responses;
    • Cognitive processes including the ability to think, learn, and concentrate;
    • Impulse control and other self-regulating behavior, v. self-image;
    • Relationships with others; and
    • Dissociation

CMS Guidance on Complex Trauma as an Eligible 2703 Chronic Condition.

Health Home Serving Children Serious Emotional Disturbance (SED) Definition

For Health Home Serving Children, SED is a single qualifying chronic condition and is defined as a child or adolescent (under the age of 21) that has a designated mental illness diagnosis in the following Diagnostic and Statistical Manual (DSM) categories below* as defined by the most recent version of the DSM of Mental Health Disorders AND has experienced the following functional limitations due to emotional disturbance over the past 12 months (from the date of assessment) on a continuous or intermittent basis.

SED Definition for Health Home - DSM Qualifying Mental Health Categories*

  • Anxiety Disorders
  • Bipolar and Related Disorders
  • Depressive Disorders
  • Disruptive, Impulse-Control, and Conduct Disorders
  • Dissociative Disorders
  • Obsessive-Compulsive and Related Disorders
  • Feeding and Eating Disorders
  • Gender Dysphoria
  • Paraphilic Disorders
  • Personality Disorders
  • Schizophrenia Spectrum and Other Psychotic Disorders
  • Somatic Symptom and Related Disorders
  • Trauma- and Stressor-Related Disorders
  • Sleep-Wake Disorders
  • Medication-Induced Movement Disorders
  • ADHD
  • Elimination Disorders
  • Sexual Dysfunctions
  • Tic Disorder

*Any diagnosis in these categories can be used when evaluating a child for SED. However, any diagnosis that is secondary to another medical condition is excluded.

Functional Limitations Requirements for SED Definition of Health Home - The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas as determined by a licensed mental health professional:

  • Ability to care for self (e.g., personal hygiene; obtaining and eating food; dressing; avoiding injuries); or
  • Family life (e.g., capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or
  • Social relationships (e.g., establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or
  • Self-direction/self-control (e.g., ability to sustain focused attention for a long enough period of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability); or
  • Ability to learn (e.g., school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

Health Home Appropriateness Criteria

Individuals must meet the Chronic Condition Criteria AND be Appropriate for Health Home Care Management

Appropriateness Criteria: Individuals meeting the Health Home eligibility criteria must be appropriate for the intensive level of care management provided by Health Homes. Assessing whether an individual is appropriate for Health Homes includes determining if the person is:

  • At risk for an adverse event (e.g., death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement)
  • Has inadequate social/family/housing support, or serious disruptions in family relationships;
  • Has inadequate connectivity with healthcare system;
  • Does not adhere to treatments or has difficulty managing medications;
  • Has recently been released from incarceration, placement, detention, or psychiatric hospitalization;
  • Has deficits in activities of daily living, learning or cognition issues, or
  • Is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home.
Health Home Six Core Services
  1. Comprehensive Care Management
    • A comprehensive health assessment that identifies medical, mental health, chemical dependency and social service needs is developed.
  2. Care Coordination and Health Promotion
    • The Health Home provider is accountable for engaging and retaining Health Home members in care; coordinating and arranging for the provision of services; supporting adherence to treatment recommendations; and monitoring and evaluating a patient´s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
  3. Comprehensive Transitional Care
    • The Health Home provider has a system in place with hospitals and residential/rehabilitation facilities in their network to provide the Health Home prompt notification of an individual´s admission and/or discharge to/from an emergency room, inpatient, or residential/rehabilitation setting.
  4. Patient and Family Support
    • Patient´s individualized plan of care reflects patient and family or caregiver preferences, education and support for self-management, self-help recovery, and other resources as appropriate.
  5. Referral to Community Supports
    • The Health Home provider identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up and coordination of services.
  6. Use of Health Information Technology (HIT) to Link Services
    • Health Home providers will make use of available HIT and access data through the regional health information organization/qualified entities to conduct these processes as feasible

Further information concerning and further outlining the six core services can be found here.

December 2016 Updated 3/29/17, 2/28/19, 3/2022