24 Miss. Code. R. 2-54.11 - Program Requirement Three (3): Care Coordination - General Requirements
A. Based on a person-centered and
family-centered treatment plan aligned with the requirements of the applicable
section of the Affordable Care Act and aligned with state regulations and
consistent with best practices, the CCBHC coordinates care across the spectrum
of health services. This coordination includes access to high-quality physical
health (both acute and chronic) and behavioral health care, as well as social
services, housing, educational systems, and employment opportunities as
necessary to facilitate wellness and recovery of the whole person. The CCBHC
also coordinates with other systems to meet the needs of the people they serve,
including criminal and juvenile justice and child welfare. Note: Refer
to criteria relating to care coordination requirements for veterans. (Reference
Source: For additional information on care coordination, see Care Coordination
- Agency for Healthcare Research and Quality.)
B. The CCBHC maintains the necessary
documentation to satisfy the requirements of HIPAA and other federal and state
privacy laws, including patient privacy requirements specific to the care of
minors. To promote coordination of care, the CCBHC will obtain necessary
consents for sharing information with community partners where information is
not able to be shared under HIPAA and other federal and state laws and
regulations. If the CCBHC is unable, after reasonable attempts, to obtain
consent for any care coordination activity specified in Program Requirement
Three (3), such attempts must be documented and revisited periodically.
Note: CCBHCs are encouraged to explore options for electronic
documentation of consent where feasible and responsive to the needs and
capabilities of the person receiving services. (Reference Source: The
Interoperability Standards Advisory (ISA) process represents the model by which
the Office of the National Coordinator for Health Information Technology (ONC)
coordinates the identification, assessment, and determination of "recognized"
interoperability standards and implementation specifications for industry use
to fulfill specific clinical health IT interoperability
needs.)
C. Consistent with
requirements of privacy, confidentiality, and the preferences and needs of
people receiving services, the CCBHC assists people receiving services and the
families of children and youth referred to external providers or resources in
obtaining an appointment and tracking participation in services to ensure
coordination and receipt of supports.
D. The CCBHC shall coordinate care in keeping
with the preferences of the person receiving services and their care needs. To
the extent possible, care coordination should be provided, as appropriate, in
collaboration with the family/caregiver of the person receiving services and
other supports identified by the person. To identify the preferences of the
person in the event of psychiatric or substance use crisis, the CCBHC develops
a crisis plan with each person receiving services. At a minimum, people
receiving services should be counseled about the use of the National Suicide
and Crisis Lifeline, local hotlines, warmlines, mobile crisis, and
stabilization services should a crisis arise when providers are not in their
office. Crisis plans may support the development of a Psychiatric Advance
Directive, if desired by the person receiving services. Psychiatric Advance
Directives, if developed, are entered in the electronic health record of the
person receiving services so that the information is available to providers in
emergency care settings where those electronic health records are accessible.
Psychiatric Advance Directives are legal instruments that may be used to
document a competent person's specific instructions or preferences regarding
future mental health treatment. Psychiatric Advance Directives can be used to
plan for the possibility that someone may lose capacity to give or withhold
informed consent to treatment during acute episodes of psychiatric illness.
(Reference Source: For more information visit NRC PAD - National
Resource Center on Psychiatric Advance Directives.)
E. Appropriate care coordination requires the
CCBHC to make and document reasonable attempts to determine any medications
prescribed by other providers. To the extent that state laws allow, the state
Prescription Drug Monitoring Program (PDMP) must be consulted before
prescribing medications. The PDMP should also be consulted during the
comprehensive evaluation. Upon appropriate consent to release information, the
CCBHC is also required to provide such information to other providers not
affiliated with the CCBHC to the extent necessary for safe and quality
care.
F. Nothing about a CCBHC's
agreements for care coordination should limit the freedom of a person receiving
services to choose their provider within the CCBHC, with its DCOs, or with any
other provider.
G. The CCBHC
assists people receiving services and families to access benefits, including
Medicaid, and enroll in programs or supports that may benefit them.
Notes
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