Performance Management

The Health Home Performance Management Program (PM) provides a formal framework for Health Homes, Care Management Agencies, Managed Care Plans and the State to work together to improve health outcomes of Health Home members.

Successful PM requires concerted and tactical efforts by Lead Health Homes to actively monitor performance measures and manage practices, processes and providers to ensure Health Home care management is providing value and improving health outcomes.

The PM Program includes specific measures that lead to short term and longer term performance outcomes to achieve the vision of health, wellbeing, and recovery for Health Home members. All Quality Measures are reported to CMS on an annual basis. All Process Measures are utilized to assess Health Home and Care Management Agency´s quality of care. The PM Program includes but is not limited to individualized technical assistance, learning collaboratives, redesignation support and quality/performance improvement webinars and activities.

The NYSDOH and the State Agency Partners (OMH, OASAS and AIDS Institute) identified a subset of measures in 2016 that required additional focus and data analysis by the lead Health Homes.

In 2013, the Center for Medicaid and CHIP Services (CMS) recommended a core set of health care quality measures.

The Health Home Core Set Manual identifies the technical specification and resources required for data collection and reporting.

The State Plan Amendment identifies a set of Quality Measures that falls within three categories: Clinical Outcomes, Experience of Care and Quality of Care.

The HARP Quarterly Progress Report must be completed by Lead Health Homes and submitted on a quarterly basis, as per the table below.

Reporting Period Report Due Date
September 2017 – November 2017 1/5/18
December 2017 – February 2018 4/5/18
March 2018 – May 2018 7/5/18
June 2018 – August 2018 10/5/18

The Health Home Care Management Assessment Reporting Tool (HH–CMART) is a tool for the collection of standardized care management data for members in outreach or enrolled in a Health Home. 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 following link is for the Lead Health Homes. CMAs must submit data to their lead Health Home.

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. Any questions on the HH CMART documents can be directed to the Health Home program by clicking here.

NYS DOH and Salient HHS jointly developed the MAPP dashboards to support the Health Home provider community with program oversight and performance management. The dashboards provide actionable data to help improve the goals of the Health Home program.

The Salient Health Home Dashboards include utilization and enrollment data from New York State Medicaid paid fee–for–service claims and managed care encounters, as well as from the Health Home Tracking System. The major source of the Health Home data is the Health Home Tracking System (input by the Health Home provider system), with the claims, encounters and dollars coming from the Medicaid Data Warehouse. The dashboards are updated monthly with new data.

The dashboards use Health Home tracking data and visit counts dating back to January 1, 2012, which was the start of the Health Home program. In the first few months, the data are attributed to "legacy programs," i.e., Health Homes covered from prior Therapeutic Case Management (TCM) programs.

You must be both a Health Commerce System (HCS) and MAPP User to access the MAPP Dashboards. Go to the Frequently Asked Questions under "MAPPHHTS Organizational Access" for instructions on how to become a HCS user and "MAPP HHTS End–User Access" for instructions on how to become a MAPP user.

What is Re–Designation?

After the initial three year period of designation, DOH is required to review Health Home performance to determine whether Health Homes should be approved to operate beyond the initial three year designation period. The Department and its State Agency Partners (Office of Mental Health, AIDS Institute, and Office of Alcoholism and Substance Abuse Services) will conduct a collaborative review to determine whether Health Homes across the State are in compliance with Health Home standards and requirements. CASA Columbia is also a partner in the Re-Designation process and will gather information for its overall evaluation of the Health Home Program in New York State.

Re–Designation of Health Homes will be determined based on:

  • Compliance with Federal and State standards and requirements
  • Health Home goals to reduce preventable hospitalizations and emergency room visits, and avoid unnecessary care
  • Governance and operational integrity
  • Evidence of positive interventions, integration of care and improved outcomes for members
  • Ability to develop capacity and capabilities to fully participate in the Behavioral Health integration, DSRIP and other state initiatives

Health Home Re–Designation Site Visit Standards and Chart Review Tools

Standards Tool

Health Home Re–Designation Chart Review Tool

Assessment

The following documents represent the versions of the FACT–GP and the Health Home Functional Assessment that were used by each Health Home at enrollment, annually and at discharge.

The FACT–GP and Functional Assessment does 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.

FACT–GP

*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