SCO Health Home Care Management Referral Checklist

The following is a list of required materials necessary to submit an application to the SCO Care Management program. Please submit a complete packet of required documentation as specified below.

Incomplete packets WILL NOT be processed and will be returned.

CCF Universal Referral & Eligibility Application Form (pg. 1 of version: Revised 7-11-17)‐ Must be completed in its Entirety Clinical Documentation REQUIRED by eligibility type as indicated on application form:

Two or more Chronic Conditions (see appendix A of application form for a detailed list of eligible chronic conditions)

o Medical/Physical evaluation to include diagnosis dated within 12 months of referral

HIV/AIDS

o Medical/Physical evaluation to include diagnosis dated within 12 months of referral

Serious Emotional Disturbance (See appendix B of application for specific guidance for SED eligibility)

o Psychological Evaluation (signed and dated within 12 months of referral ) OR o Psychiatric Evaluation (signed and dated within 12 months of referral) OR o Mental Health Assessment/ Psychosocial Assessment (signed and dated within 12 months of referral)

completed by a Licensed Professional

All above assessments/evaluations MUST include diagnosis and describe/identify functional limitations due to emotional disturbance within the past 12 months of date of referral on a continuous or intermittent basis.

Definition of “Licensed Professional”: Licensed Master Social Worker-LMSW, Licensed Clinical Social Worker-LCSW, Psychologist, Psychiatrist, Licensed Nurse Practitioner-LNP, Licensed Marriage & Family Therapist-LMFT, Licensed Mental Health Counselor-LMHC, Psychiatric Nurse Practitioner.

Complex Trauma (See appendix C of application for specific guidance for Complex trauma eligibility)

o Complex Trauma Referral Cover Sheet and Exposure Screening form (can be completed by a non-

licensed or licensed professional)

Please scan completed package and email to: healthhome@sco.org

***Please note that date a COMPLETED package is received through email is the ACTUAL referral date***

Collaborative for Children and Families

HEALTH HOME

UNIVERSAL REFERRAL & ELIGIBILTY APPLICATION FORM

Revised 7-11-17

INSTRUCTIONS: This form is to be completed in its entirety in order to make a referral to a Health Home. Please attach any clinical documentation to support eligibility.

TODAY’S DATE: DATE OF BIRTH:

MEMBERS NAME, (LAST, FIRST, MI,) (Include any alias, nicknames or other names the child/youth may be known

MEMBERS CURRENT ADDRESS:

CITY:

ZIP:

COUNTY OF RESIDENCE:

GENDER: Male Female

LANGUAGE PREFERENCE OTHER THAN ENGLISH (INCLUDING

AMERICAN SIGN LANGUAGE):

MEMBERS HOME PHONE #: MEMBER’S CELL PHONE #:

INSURANCE

MEDICAID/CIN #:

MCO PLAN NAME: (If any) If copy of Medicaid card available please attach

PERMISSION TO REFER: You must identify that consent to refer has been obtained and who has given consent to refer. Please note that this can be a verbal consent received.

PLEASE INDICATE THE INDIVIDUAL FROM WHOM YOU HAVE OBTAINED CONSENT TO REFER THIS MEMBER TO THE HEALTH HOME PROGRAM

Parent Guardian Legally authorized representative member/self/individual if 18 years or older member/self/individual under 18, but is a parent, pregnant, or married.

DATE PERMISSION TO REFER WAS OBTAINED:

PARENT/LEGAL GUARDIAN or LEGALLY AUTHORIZED REPRESENTATIVE [I.E. MEDICAL CONTER]

CONSENTER’S NAME: RELATIONSHIP TO MEMBER:

CONSENTER’S ADDRESS: CITY:

STATE: ZIP CODE:

GUARDIAN’s PHONE #s:

H:

C: CONSENTER’S E-MAIL ADDRESS:

IS MEMBER IN FOSTER CARE? Yes NO Unknown

FAMILY/RESIDENTIAL INFORMATION

IS MEMBER’S PARENT/GUARDIAN CURRENTLY ENROLLED IN A HEALTH HOME? YES NO UNKNOWN

IF YES, FAMILY MEMBER NAME: RELATIONSHIP TO REFERRED MEMBER:

IF YES, HEALTH HOME NAME: IF YES, CARE MANAGEMENT AGENCY:

HEALTH HOME ELIGIBILITY CRITERIA (* Note: if documentation is available to support any of these conditions please attach)

ELIGIBILITY TYPE (if ICD10 code available please provide)

APPROPRIATENESS CRITERIA (Check all that apply)

At risk for adverse event (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

Is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home

Two or More Chronic Conditions. List Conditions:

1.

2.

OR one of the following single qualifying conditions

Serious Emotional Disturbance (SED)

List condition: OR

complex trauma OR

HIV/AIDS

REFERRAL SOURCE:

Hospital MCP VFCA LDSS Preventive Services Community Based Organization School

Primary Care Physician Mental Health Provider Specialist LGU SPOA Other Referral Source:

REFERRAL ORGANIZATION: NAME OF PERSON MAKING REFERRAL:

PERSON MAKING REFERRAL CONTACT INFO:

PHONE: E-MAIL:

PREFERRED OR RECOMMENDED HEALTH HOME (SEE LIST ATTACHED:

Appendix A: Health Home Chronic Conditions List* *9/23/14 updated 3/2/17

Qualifying chronic conditions are any of those included in the “Major” categories of the 3MTM Clinical Risk Groups (CRGs) as described in the list below:

Major Category: Alcohol and Substance Use Disorder

Alcohol and Liver Disease

Chronic Alcohol Abuse

Cocaine Abuse

Drug Abuse – Cannabis/NOS/NEC

Substance Abuse

Opioid Abuse

Other Significant Drug Abuse Major Category: Mental Health

Bi-Polar Disorder

Conduct, Impulse Control, and Other Disruptive Behavior Disorders

Dementing Disease

Depressive and Other Psychoses

Eating Disorder

Major Personality Disorders

Psychiatric Disease (Except Schizophrenia)

Schizophrenia Major Category: Cardiovascular Disease

Advanced Coronary Artery Disease

Cerebrovascular Disease

Congestive Heart Failure

Hypertension

Peripheral Vascular Disease Major Category: Metabolic Disease

Chronic Renal Failure

Diabetes Major Category: Respiratory Disease

Asthma

Chronic Obstructive Pulmonary Disease

Collaborative for Children and Families

HEALTH HOME

UNIVERSAL REFERRAL & ELIGIBILTY APPLICATION FORM

Revised 7-11-17

DETAILED CHRONIC CONDITIONS LIST

Acquired Hemiplegia and Diplegia

Acquired Paraplegia

Acquired Quadriplegia

Acute Lymphoid Leukemia w/wo Remission

Acute Non-Lymphoid Leukemia w/wo Remission

Alcoholic Liver Disease

Alcoholic Polyneuropathy

Alzheimer's Disease and Other Dementias

Angina and Ischemic Heart Disease

Anomalies of Kidney or Urinary Tract

Apert's Syndrome

Aplastic Anemia/Red Blood Cell Aplasia

Ascites and Portal Hypertension

Asthma

Atrial Fibrillation

Attention Deficit / Hyperactivity Disorder

Benign Prostatic Hyperplasia

Bi-Polar Disorder

Blind Loop and Short Bowel Syndrome

Blindness or Vision Loss

Bone Malignancy

Bone Transplant Status

Brain and Central Nervous System Malignancies

Breast Malignancy

Burns - Extreme

Cardiac Device Status

Cardiac Dysrhythmia and Conduction Disorders

Cardiomyopathy

Cardiovascular Diagnoses requiring ongoing evaluation and treatment

Cataracts

Cerebrovascular Disease w or w/o Infarction or Intracranial Hemorrhage Chromosomal Anomalies

Chronic Alcohol Abuse and Dependency

Chronic Bronchitis

Chronic Disorders of Arteries and Veins

Chronic Ear Diagnoses except Hearing Loss

Chronic Endocrine, Nutritional, Fluid, Electrolyte and Immune

Diagnoses

Chronic Eye Diagnoses

Chronic Gastrointestinal Diagnoses

Chronic Genitourinary Diagnoses

Chronic Gynecological Diagnoses

Chronic Hearing Loss

Chronic Hematological and Immune Diagnoses

Chronic Infections Except Tuberculosis

Chronic Joint and Musculoskeletal Diagnoses

Chronic Lymphoid Leukemia w/wo Remission

Chronic Metabolic and Endocrine Diagnoses

Chronic Neuromuscular and Other Neurological Diagnoses

Chronic Neuromuscular and Other Neurological Diagnoses

Chronic Non-Lymphoid Leukemia w/wo Remission

Chronic Obstructive Pulmonary Disease and Bronchiectasis

Chronic Pain

Chronic Pancreatic and/or Liver Disorders (Including Chronic Viral Hepatitis) Chronic Pulmonary Diagnoses

Chronic Renal Failure

Chronic Skin Ulcer

Chronic Stress and Anxiety Diagnoses

Chronic Thyroid Disease

Chronic Ulcers

Cirrhosis of the Liver

Cleft Lip and/or Palate

Coagulation Disorders

Cocaine Abuse

Colon Malignancy

Complex Cyanotic and Major Cardiac Septal Anomalies

Conduct, Impulse Control, and Other Disruptive Behavior Disorders

Congestive Heart Failure

Connective Tissue Disease and Vasculitis

Coronary Atherosclerosis

Coronary Graft Atherosclerosis

Crystal Arthropathy

Curvature or Anomaly of the Spine

Cystic Fibrosis

Defibrillator Status

Collaborative for Children and Families

HEALTH HOME

UNIVERSAL REFERRAL & ELIGIBILTY APPLICATION FORM

Revised 7-11-17

Dementing Disease

Depression

Depressive and Other Psychoses

Diabetes w/wo Complications

Digestive Malignancy

Disc Disease and Other Chronic Back Diagnoses w/wo Myelopathy

Diverticulitis

Drug Abuse Related Diagnoses

Ear, Nose, and Throat Malignancies

Eating Disorder

Endometriosis and Other Significant Chronic Gynecological Diagnoses

Enterostomy Status

Epilepsy

Esophageal Malignancy

Extrapyramidal Diagnoses

Extreme Prematurity - Birthweight NOS

Fitting Artificial Arm or Leg

Gait Abnormalities

Gallbladder Disease

Gastrointestinal Anomalies

Gastrostomy Status

Genitourinary Malignancy

Genitourinary Stoma Status

Glaucoma

Gynecological Malignancies

Hemophilia Factor VIII/IX

History of Coronary Artery Bypass Graft

History of Hip Fracture Age > 64 Years

History of Major Spinal Procedure

History of Transient Ischemic Attack

HIV Disease

Hodgkin's Lymphoma

Hydrocephalus, Encephalopathy, and Other Brain Anomalies

Hyperlipidemia

Hypertension

Hyperthyroid Disease

Immune and Leukocyte Disorders

Inflammatory Bowel Disease

Intestinal Stoma Status

Joint Replacement

Kaposi's Sarcoma

Kidney Malignancy

Leg Varicosities with Ulcers or Inflammation

Liver Malignancy

Lung Malignancy

Macular Degeneration

Major Anomalies of the Kidney and Urinary Tract

Major Congenital Bone, Cartilage, and Muscle Diagnoses

Major Congenital Heart Diagnoses Except Valvular

Major Liver Disease except Alcoholic

Major Organ Transplant Status

Major Personality Disorders

Major Respiratory Anomalies

Malfunction Coronary Bypass Graft

Malignancy NOS/NEC

Mechanical Complication of Cardiac Devices, Implants and

Grafts Melanoma

Migraine

Multiple Myeloma w/wo Remission

Multiple Sclerosis and Other Progressive Neurological

Diagnoses Neoplasm of Uncertain Behavior

Nephritis

Neurodegenerative Diagnoses Except Multiple Sclerosis and Parkinson's Neurofibromatosis

Neurogenic Bladder

Neurologic Neglect Syndrome

Neutropenia and Agranulocytosis

Non-Hodgkin's Lymphoma

Obesity (BMI at or above 25 for adults and BMI at or

above the 85th percentile for children)

Opioid Abuse

Osteoarthritis

Osteoporosis

Other Chronic Ear, Nose, and Throat Diagnoses

Other Malignancies

Pancreatic Malignancy

Pelvis, Hip, and Femur Deformities

Peripheral Nerve Diagnoses

Peripheral Vascular Disease

Persistent Vegetative State

Phenylketonuria

Collaborative for Children and Families

HEALTH HOME

UNIVERSAL REFERRAL & ELIGIBILTY APPLICATION FORM

Revised 7-11-17

Pituitary and Metabolic Diagnoses

Plasma Protein Malignancy

Post-Traumatic Stress Disorder

Postural and Other Major Spinal Anomalies

Prematurity - Birthweight < 1000 Grams

Progressive Muscular Dystrophy and Spinal Muscular Atrophy

Prostate Disease and Benign Neoplasms - Male

Prostate Malignancy

Psoriasis

Psychiatric Disease (except Schizophrenia)

Pulmonary Hypertension

Recurrent Urinary Tract Infections

Reduction and Other Major Brain Anomalies

Rheumatoid Arthritis

Schizophrenia

Secondary Malignancy

Secondary Tuberculosis

Sickle Cell Anemia

Significant Amputation w/wo Bone Disease

Significant Skin and Subcutaneous Tissue Diagnoses

Spina Bifida w/wo Hydrocephalus

Spinal Stenosis

Spondyloarthropathy and Other Inflammatory Arthropathies

Stomach Malignancy

Tracheostomy Status

Valvular Disorders

Vasculitis

Ventricular Shunt Status

Vesicostomy Status

Vesicoureteral Reflux

Appendix B: Serious Emotional Disturbance (SED)

SED Definition for Health Home - SED is a single qualifying chronic condition for Health Home and is defined as a child or adolescent (under the age of 21) that has a designated mental illness diagnosis in Diagnostic and Statistical Manual (DSM). Note: the DSM categories include in the definition of SED used to determine Health Home eligibility is different than the SED definition used to determine eligibility for other Medicaid services (e.g., OMH clinic, inpatient, etc.) “ Categories” can be used when evaluating a child for SED. However, any diagnosis that is secondary to another medical condition is excluded as defined by the most recent version of the DSM of Mental Health Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Bipolar and Related Disorders

Depressive Disorders

Anxiety Disorders

Obsessive Compulsive and Related Disorders

Feeding and Eating Disorders

Disruptive, Impulse Control, and Conduct Disorders

Personality Disorders

Paraphilic Disorders

ADHD for children who have utilized any of the following services in the past three years:

o Psychiatric inpatient o Residential Treatment Facility o Day treatment o Community residence o Mental Health HCBS & OCFS B2H Waiver o OMH Targeted Case Management

Functional Limitations Requirements for SED Definition of Health Home: To meet definition of SED for Health

Home the child must have 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.

The functional limitations must be moderate in at least two of the following areas or severe in at least one of

the following areas:

- 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 a 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 period of time to permit completion of age appropriate tasks; behavioral self-control; appropriate judgement 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)

Appendix C: Complex Trauma

Definition of Complex Trauma: A) The term complex trauma incorporates at least:

a. Infants/Children/or Adolescents exposure to multiple traumatic events, often of an invasive, interpersonal nature, and

b. The wide-ranging, long term impact of this exposure

B) The nature of the traumatic events: a. Often is severe and pervasive, such as abuse or profound neglect; b. Usually begins early in life; c. Can be disruptive of the child’s development and the formation of health sense of self (with self-regulatory,

executive functioning, self-perceptions etc.); d. Often occur in the context of the child’s relationship with a caregiver; and e. Can interfere with the child’s ability to form a secure attachment bond, which is considered a prerequisite for

health social-emotional functioning

C) Many aspects of a child’s healthy physical and mental development rely on this secure attachment, a primary source of safety and stability

D) Wide-ranging, long term adverse effects can include impairments in: a. Physiological responses and related neurodevelopment b. Emotional Responses c. Cognitive processes including the ability to think, learn and concentrate d. Impulse control and other self-regulating behavior e. Self-image; f. Relationships with others

*If child/youth eligibility is determined under the Complex Trauma, the Complex Trauma Exposure Screen Form and

Referral Cover Sheet are required upon referral, which can be completed by non-licensed or licensed professional. Obtain forms from the following links through the NYS Department of Health Website.

Complex Trauma Exposure Screen Form https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/final_complex_trauma_exp

osure_screen.pdf

Referral Cover Sheet https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/final_complex_trauma_referral_cover_sheet.pdf

Appendix D: Appropriateness Criteria

Members who are enrolled in the Health Home Program must also meet Appropriateness Criteria. A quick assessment can be

performed for all presumptively eligible individuals to evaluate whether the person has significant risk factors. Determinants of medical, behavioral, and/or social risk can include:

Probable risk for adverse events (e.g., death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement);

Lack of or inadequate social/family/housing support, or serious disruptions in family relationships;

Lack of or inadequate connectivity with healthcare system;

Non-adherence to treatments or medication(s) or difficulty managing medications;

Recent release from incarceration, detention, psychiatric hospitalization or placement;

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.

Substance use disorders (SUDS) are considered chronic conditions, but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition (as described below) to qualify.

Note: The diagnostic eligibility criteria must be verified for community referrals. Other sources such as medical records or assessments can also be used to document diagnostic eligibility.