Purpose: To describe the specific requirements, timeline, and provider compliance plan for the member Initial Health Assessment (IHA), including administration of the Staying Healthy Assessment (SHA) or other DHCS-approved Individual Health Education Behavioral Assessment (IHEBA). Policy: All contracted primary care providers (PCPs) must complete and document all components of the IHA within 120 days of member s enrollment with the plan. The IHA enables the member s PCP to assess and manage acute, chronic, and preventive health needs of the member. Performance of the IHA for all new Medi-Cal Members, including Seniors and Persons with Disabilities (SPD), is part of the contractual obligation as specified in the Case Management section of the PCP contract. The IHA must consist of at least the measures listed in Attachment A Guidelines for Completing the Initial Health Assessment. (DHCS Medi-Cal Contract Exhibit A, Attachment 10, Provision 3) Definitions: Initial Health Assessment (IHA): The IHA is a comprehensive assessment during the member s initial encounter with a selected Primary Care Provider (PCP), appropriate medical specialist, or non-physician medical provider (NPMP). Individual Health Education Behavioral Assessment (IHEBA): The IHEBA enables a provider of primary care services to comprehensively assess the member s current acute, chronic, and preventive health needs as well as identify those members whose health needs require coordination with appropriate community resources and other agencies. Staying Healthy Assessment (SHA): The SHA is a standardized IHEBA tool created by DHCS to be used for all Medi-Cal members. Procedures: 1) Central California Alliance for Health (the Alliance) will generate a monthly list of linked members for each PCP. Providers can access the list through the Provider Portal on the internet. Providers who do not have a web account can request assistance from Provider Services with setting up an account, or may request a printed list. The list will include, if available: a) Member name b) Enrollment date c) Date of birth d) Language preference 1 of 6
e) Address and telephone number 2) New members linked to the practice will appear in the list of all linked members, and will also be listed under the 120 Day IHA tab along with the IHA due dates. The list of newly linked members is for the purpose of assisting providers in completing IHAs in a timely fashion. Members must receive the IHA within 120 days of enrollment with the plan. 3) All members receive a Member Handbook / Evidence of Coverage, which informs members about the importance of contacting their PCP right away to schedule a new member exam or IHA. 4) Providers are educated about performing the IHA through provider workshops, the Provider Bulletin, information available on the Alliance website, and/or individual education by Provider Services Representatives, Quality Improvement Nurses, or the Health Education Coordinator III. 5) Providers must administer an Individual Health Education Behavioral Assessment (IHEBA) as part of the IHA, and re-administer at appropriate age intervals thereafter to all new members, including SPD members, as outlined by MMCD Policy Letter 13-001. The Staying Healthy Assessment (SHA) is the DHCS s IHEBA. The Alliance encourages the use of the DHCS-approved SHA for this purpose (see Attachment A for more information and resources to assist providers). 6) Administration of the SHA may be done in the following ways: a) Self-completion of the SHA in a waiting or exam room prior to the exam or; b) Patients may be asked SHA questions verbally and responses recorded directly in the patient s electronic medical record or SHA questionnaire form. If answers to questions are recorded directly in the patient s electronic medical record, then all of the SHA components must be included. The SHA must incorporate educational interventions (such as counseling and referral) for any identified risk behaviors, and providers must document as such in the patient s chart. Providers will make arrangements for follow-up services and plans of care that reflect the findings and risk factors determined during the IHA.(DHCS Medi-Cal Contract Exhibit A, Attachment 10, Provision 8.A.9) 7) PCPs are required to make at least three documented attempts that demonstrate unsuccessful efforts to contact a Member to schedule an IHA, including at least one telephone contact and one written contact. If the PCP is unable to reach the member or 2 of 6
the member refuses an appointment, Member Services should be contacted for assistance. The PCP must attempt to perform the IHA at subsequent member office visits, even if the 120-day period has lapsed. 8) PCPs must submit claims and encounter data for each IHA. The Alliance tracks and monitors IHAs by claims data and Facility Site Reviews. 9) PCPs will ensure that completed IHAs are included in each member s medical record and are available during subsequent visits. References:Alliance Policies: 401-1502 Adult Preventive Care 401-1505 Childhood Preventive Care Regulatory: Contractual: Medi-Cal Contract Exhibit A, Attachment 10; Medi-Cal Contract Exhibit A, Attachment 10, Provision 3; Medi-Cal Contract Exhibit A, Attachment 10, Provision 5.A; Medi-Cal Contract Exhibit A, Attachment 10, Provision 6.A; Medi- Cal Contract Exhibit A,Attachment 10, Provision 8.A.9 Legislative: MMCD Policy Letter: No. 13-001 June 28, 2013 MMCD Policy Letter: No. 08-003 May 5, 2008 Supersedes: Other: Attachment A Guidelines for Completing the Initial Health Assessment Provider Manual Initial Health Assessment Lines of Business This Policy Applies To LOB Effective Dates Medi-Cal (01/01/1996 present) Healthy Families (07/01/1998 01/31/2014) Healthy Kids Santa Cruz (07/01/2004 present) Alliance Care IHSS (07/01/2005 - present) Access for Infants and Mothers (02/1/2009 present) Individual Conversion Plan (01/01/2005-01/01/2014) Santa Cruz County LIHP (1/1/2012 12/31/2013) Monterey County LIHP (3/1/2013 12/31/2013) 3 of 6
Revision History: Review Date Revised Date Changes Made By Approved By 01/01/1999 01/01/1999 Barbara Flynn, RN Barbara Flynn, RN 10/01/2001 10/01/2001 Barbara Flynn, RN Barbara Flynn, RN 10/01/2002 10/01/2002 Barbara Flynn, RN Barbara Flynn, RN 09/01/2003 09/01/2003 Barbara Flynn, RN Barbara Flynn, RN 10/01/2004 10/01/2004 Barbara Flynn, RN Barbara Flynn, RN 10/01/2005 10/01/2005 Barbara Flynn, RN Barbara Flynn, RN 09/01/2008 09/01/2008 Barbara Flynn, RN Barbara Flynn, RN 03/01/2009 03/01/2009 Barbara Flynn, RN Barbara Flynn, RN 03/01/2010 Barbara Flynn, RN Barbara Flynn, RN 11/1/2011 11/1/ 2011 David Altman, MD, David Altman, MD, AMDQI 09/14/2012 09/14/2012 Kaite McGrew Barbara Flynn, RN, QI Dir. 11/30/2012 11/30/2012 Andres Aguirre David Altman, MD, AMDQI 05/20/2013 05/20/2013 Kelly Salazar, RN, CQIW FSR Nurse 07/11/2013 07/11/2013 Kelly Salazar, RN, CQIW FSR Nurse 03/17/2014 03/17/2014 Kelly Salazar, RN, QI Nurse CQIW 4 of 6
Guidelines for Completing the Initial Health Assessment (IHA) 401-1511 Attachment A Revised 7/11/13 The Department of Health Care Services require providers to perform an Initial Health Assessment (IHA) on new members within 120 days of enrollment. The IHA allows the Primary Care Provider and member to meet, identify and address current care needs, and form a working partnership toward managing the member s health. This chart outlines requirements for each age group. Per state regulations, the IHA must include an Individual Health Education Behavioral Assessment, using the Staying Healthy Assessment (SHA) tool, or an alternative tool that has been pre-approved by the state. How the Alliance Can Help Each month, the Alliance provides you with a list of your linked members due for an IHA. You can print the SHA forms from the DHCS website as you need them, or you can request that a supply of forms be printed and mailed to you. Please visit our website for forms and information at http://www.ccah-alliance.org/risk.html. We encourage all members to schedule their Initial Health Assessment when they join the plan. We mail preventive care reminders for childhood immunizations, breast and cervical cancer screening, adolescent well-care, flu shots, and others. We have outreach and incentive programs for immunization, adolescent well-care, prenatal and postpartum care, asthma, and diabetes. We offer special Alliance benefits for breastfeeding support and diabetes and asthma self-management. We also provide smoking cessation scholarships. We educate members on many health topics in our quarterly newsletter, and refer members to community resources on request. We assist members and providers with easy-to-read health education materials. For more information on the IHA and Clinical Health Education programs, please contact the Health Education Coordinator III by calling the Health Education Line at 831-430-5580. Important notes on IHA: Providers are required to make at least three attempts documented in the medical record that demonstrate unsuccessful efforts to contact a Member to schedule an IHA, including at least one telephone contact and one written contact. If the provider is unable to reach the member or the member refuses an appointment, Member Services should be contacted for assistance. The PCP should attempt to perform the IHA at subsequent member office visits, even if the 120-day period has lapsed. Members who change their PCP within 120 days of enrollment must receive an IHA within the initial 120 day period. For Medi-Cal members 0-20 years, bill for the IHA on a CHDP (PM160) claim form with appropriate CHDP procedure codes. It is the providers responsibility to code appropriately. Refer to the Provider Manual, Initial Health Assessment section, as a guide for IHA service billing and reporting codes. Member Age 0 to < 18 months Initial Health Assessment Criteria Comprehensive History All elements of preventive health services as outlined in Alliance Policy 401-1505 Childhood Preventive Care Comprehensive physical and mental status exam Behavioral Health Assessment with Staying Healthy Assessment Timeline For members < 18 months at the time of enrollment, the IHA will be due at the next American Academy of Pediatrics (AAP) recommended periodic health assessment, which in all cases will be less than 120 days.(dhcs Medi-Cal Contract Exhibit A, Attachement 10, Provision 5) Identified diagnoses and plan of care 5 of 6
Guidelines for Completing the Initial Health Assessment (IHA), continued Member Age Initial Health Assessment Criteria Timeline 18 months 20 years Comprehensive History All elements of preventive health services as outlined in Alliance Policy 401-1505 Childhood Preventive Care Comprehensive physical and mental status exam For members 18 months, the IHA should be performed within 120 days of enrollment..(dhcs Medi-Cal Contract Exhibit A, Attachement 10, Provision 5) Behavioral Health Assessment with Staying Healthy Assessment Identified diagnoses and plan of care 21 years and older Comprehensive History All elements of preventive health services as outlined in Alliance Policy 401-1502 Adult Preventive Care Comprehensive physical and mental status exam For members > 21 years, the IHA should be performed within 120 days of enrollment..(dhcs Medi-Cal Contract Exhibit A, Attachement 10, Provision 6) Behavioral Health Assessment with Staying Healthy Assessment Identified diagnoses and plan of care Pregnant Women A comprehensive initial prenatal visit must be initiated as soon as possible after enrollment or discovery that the member is pregnant. The initial prenatal visit will also serve as the IHA for these members, if performed within 120 days of enrollment. Providers are encouraged to follow ACOG and CPSP preventive care screening guidelines. Note: Prior authorization is not required for basic obstetrical services. Members Hospitalized during the initial 120-day enrollment period The admitting history and physical combined with the post-discharge office visit will meet IHA requirements, if all IHA content requirements, including the provision of all necessary preventive services, are provided or arranged for during hospitalization and post-discharge visit. The IHA should be performed within 120 days of enrollment. 6 of 6