New York State DOH
Health Home Care Management
Reporting Tool (HH-CMART)
Support Calls – Session #5
March 20,2013
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Technical Specifications Update
Q+A Themes from previous calls
Reminder: HH-CMART Data Flow
Definitions of Elements 27–34
Questions and Comments
Feedback, Help, and Ongoing Support
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Please submit your questions in writing to the
webinar
 If you would like to ask your questions, raise
your hand (making sure you have entered
your audio pin code) and we will unmute the
call one at a time
 We are working on a Question and Answer
document that will be posted on the HH
website under the HH-CMART section
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Question and Answer Themes
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Can more than one person enter data at the same
time in the HH CMART tool if the tool is placed on
a shared drive?
The
HH CMART tool can reside on a shared drive, and two
or more people can enter the data at the same time on
different individuals. But two people cannot enter data for
the same individual at the same time.
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Does the FACT GP / HH Functional assessment scores need to
be submitted from ‘converting to health home’ legacy
members and all other Health Home members enrolled in
2012?
 Yes, the FACT GP/ HH Functional assessment scores are required
to be submitted for all converting TCM clients and other active
members of HH for 2012
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How do I submit the 2012 Fact GP/ HH Functional
assessment scores?
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The Health Home and the Care Manager / downstream provider
should develop a process using the excel spreadsheet DOH sent
out. See 3/13/2013 webinar, slides 4, 6 ,& 7 for more
information or contact [email protected] for a copy
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Can care manager / downstream provider share data from
the Fact GP/ HH Functional Assessments with a Health
Home when the clients are ‘case closed’ and/ or a
withdrawal of consent was signed?
Retraction of Exception on Slide 9 from 3/6/13 Webinar:
After consultation with DOH legal (DLA), there is no longer an
exception to sharing FACT GP/ HH Functional Assessment
Data. Signed withdrawal of consent does not prohibit the
Care Manager (CM) from sharing data with Health Home(HH)
Upcoming HH webinar for Q’s on sharing data & terms of the
DEA & Subcontractor packet
CM downstream provider assessment data can be shared
with the HH as long as there is an agreement (Subcontractor
packet ) between the HH and CM downstream provider.
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If 2012 HH members do not have completed initial FACT-GP
/ HH Functional assessments
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You do not need to report using the excel spreadsheet or the CMART
tool for the TCM legacy clients and other HH members served during
2012
What does the care manager or HH do if I the 2012 FACT GP/
HH Functional Assessments were not done?
 Go Forward: Perform initial FACT GP/ HH Functional
assessments now on any converting TCM member or Health
Home member currently receiving services and enter it into
the HH CMART tool
 Submit assessment scores with all other HH CMART data to
the Health Home for first two quarters of 2013 – (see report
schedule for the August 5th submission date)
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Question and Answer Themes
From March 13 Call
How
do I submit the first two quarters of 2013 HH
CMART data, due August 5th, 2013 ?
 CM & HH must discuss / plan how to collect &
then export the data to the HH
Collection / Export suggestions:
CM
should use a separate HH CMART tool
Or use a separate HH CMART export template spreadsheet
Or whatever method HH & CM agreed upon
Once compiled, CM sends it to HH’s you have an agreement
with so the HH can report it to NYS DOH
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Care Manager Collects
Care managers will
provide needed
information about
services provided to
the Health Home
Health Home compiles
Health Home collects
data from all care
management staff
involved with its
members
Health Home submits to SDOH
Health Home enters or
imports data for all
members assigned to
the Health Home into
the tool and submits
HH-CMART to DOH
*Flow diagram reference: HH CMART Technical Requirements Specification document , page 4
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Care Management Providers: Collect the data needed for HH-CMART
submission, (either in the HH-CMART tool or in the excel template file) using the
specifications and response options for each element.
◦ For any care management provider managing members for more than one Health Home,
multiple HH-CMART files can be used. Make a copy of the HH CMART Tool to use for each of
the health homes separately prior to entering any data. You should not use the same health
home CMART Tool for entering more than one health home’s data.
◦ At the end of the reporting period, the care management provider securely transmits a file
to each Health Home, containing the data for that Health Homes members.
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Health Homes: gather the HH – CMART data from all care management
providers for their members and aggregate all of the data files into ONE Health
Home file. The Health Home’s single file is imported into one HH-CMART tool
for that reporting period.
A single HH-CMART export file ( compilation of all CM providers/ partners) for
the Health Home is sent to DOH by the Health Home via the Health Commerce
System.
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Each element is color coded by data collection needs for each
element by reporting period
◦ Green = changes each reporting period
◦ Red = Once in, remains the same always
◦ Orange = Needs to be reviewed for new information
each report
◦ Blue = DOH will fill in
* Color Coding See slides from Feb. 20, 2013 Webinar
power point:
http://www.health.ny.gov/health_care/medicaid/progra
m/medicaid_health_homes/meetings_webinars.htm
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27 –CaseReopened: Indicates whether a member is located and reengaged in care
management after case closure.
◦ This element should indicate ‘REOPENED’ if there is a subsequent engagement of care management
initiated during the reporting period, regardless of program or reason for care management.
◦The reopening of the case will be documented in the CaseReopened field in the appropriate quarter
reporting period when the reopening occurs.
Distinguishing when care management is reopened –
◦ If care management services for the member has been closed (due to inactivity or other reason) and, for
example, the health home policy for case reopened is to conduct a new assessment and start a new care plan
during the reporting period, then this should be considered a “reopening” of care management and
CaseReopened should be ’REOPENED’. Note :Care managers should follow the Health Home policy for case
reopened guidelines and determination.
◦ If care management has been closed and the subsequent reopening of care management does not start during
the reporting period, the case should be considered closed and CaseReopened should be “NOT REOPENED” for
that reporting period.
◦If care management has been inactive, and the member is located and engaged and the same assessment and
care plan are used, then these activities should be considered part of the initial care management segment. In
this situation, CaseReopened would be blank because the care management was never closed.
28 – DateReopened: Date when a member is reengaged in care management after case closure.
◦ The DateReopened will be determined through the Patient Tracking System. The date of the case
reopened will be after a segment that is the first ‘Begin Date’ following an ‘End Date’ in the Patient
Tracking System.
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Identifying, categorizing and counting care management interventions
(Elements 29-34)
◦ Each separate intervention should be counted once for an appropriate category.
◦ Only interventions which were conducted should be counted; updates scheduled but not
completed should not be included.
◦ The counts of interventions reported for a member should be limited to the reporting period
and should not include interventions from any other reporting periods. Counts are not
cumulative from the initiation of care management.
◦ The activities conducted during the reporting period for care management may involve the
member and legal representative/family, the health care providers, or other community
based services. The interventions should be specific to the individual member’s care or care
management needs.
◦ Interventions delivered by all care management staff (care managers and support staff)
should be included.
◦ Interventions conducted by Health Home or care management contracted vendors should
be counted.
◦ Interventions conducted by providers, other organizations, or health plans should not be
counted.
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Element Definitions
 Many times interventions will include a multiple
focus. Select which category that represents the primary
reason for the intervention and include in the count for that
category .
 Example: a FTF visit includes assessing a new need and during
that visit, assistance to make an appointment for the need is
provided. Primary reason for the intervention is assessing new
need, so intervention is included in CareManage for the reporting
period.
Count = 1 for CareManagement
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29 – Plan Update: Indicates whether the member’s care plan was
reviewed, updated and/or modified during the reporting period.
◦ Captures an indicator of whether the member’s care plan was reviewed, updated and
modified, if necessary, at least once during the reporting period.
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30 – CareManage: Counts of activities in the reporting period to
assess needs, monitor progress with member/legal representative and
care team, modify or update the care plan or goals.
◦ Captures the count of interventions for comprehensive care management activities
(gathering) information about needs or progress, revising or modifying the care plan, and
interacting with member and providers about modifications to the care plan) conducted
for or with the member during the reporting period.
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31 – HealthPromote: Counts of activities in the reporting period to
assist in scheduling and keeping appointments, advocate and arrange
for needed services and monitor delivery of services.
◦ Captures the count of interventions for health promotion activities (assistance in
scheduling and keeping appointments, advocating for services and arranging services)
conducted for or with the member during the reporting period.
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32 – TransitionCare: Counts of activities in the reporting period to
evaluate care needs at transitions, arrange safe transition plan, update
care team, update information with providers and care plan
◦ Captures the count of interventions for addressing transitions in care (evaluating care
needs, safe transition plan, continued care arrangements and updating providers and care
plan) conducted for or with the member during the reporting period.
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33 – MemberSupport: Counts of activities in the reporting period
to self – management, family/legal representative meetings, peer
supports, educate member rights
◦ Captures the count of interventions for providing member/family supports
(self‐management education, conducting family meetings, arranging peer or community
support programs, and educating member on rights) conducted for or with the member
during the reporting period.
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34 – CommSocial: Counts of activities in the reporting period to
collaborate with Community Based Organization for services or needs.
◦ Captures the count of interventions for addressing community based services (arranging
and coordinating community based services and supports) conducted for or with the
member during the reporting period.
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We encourage your feedback
◦ Case Scenario development
◦ Clarify fields so that the thinking behind how a question is answered in
the HH-CMART is the same across the board
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Email the Health Home Team at
[email protected]
with the Subject : HH CMART
Or Call the Health Home provider line – 518.473.5569
Health
Home website, Assessment and Quality Metrics menu, Process
Measures section:
http://www.health.ny.gov/health_care/medicaid/program/medicaid
_health_homes/assessment_quality_measures/process_measures.ht
m
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Weekly call every Wednesday from 10 a.m. to 11 a.m.
◦ The next call for March 27th, 2013 will be announced via
email and information will be posted on the HH Website
under “What’s New” menu
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Slides from all webinars can be accessed by visiting
the Health Home website at:
http://www.health.ny.gov/health_care/medicaid/program/me
dicaid_health_homes/meetings_webinars.htm
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