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: [email protected]
***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.
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