Program Requirement Three (3): Care Coordination – Care Coordination and

Program Requirement Three (3): Care Coordination – Care Coordination and Other Health Information Systems A. The CCBHC establishes or maintains a health information technology (IT) system that includes, but is not limited to, electronic health records. B. The CCBHC uses its secure health IT system(s) and related technology tools, ensuring appropriate protections are in place, to conduct activities such as population health management, quality improvement, quality measurement and reporting, reducing disparities, outreach, and for research. When CCBHCs use federal funding to acquire, upgrade, or implement technology to support these activities, systems should utilize nationally recognized, HHS-adopted standards, where available, to enable health information exchange (HIE). For example, this effort may include simply using common terminology mapped to standards adopted by HHS to represent a concept such as race, ethnicity, or other demographic information. Note: Pursuant to the HHS Health IT Alignment policy and the HITECH Act, recipients and subrecipients of award funding which involves acquiring, upgrading, and implementing health IT must utilize health IT that meets standards and implementation. While this requirement does not apply to incidental use of existing IT systems to support these activities when there is no targeted use of program funding, CCBHCs are encouraged to explore ways to support alignment with standards across data-driven activities. C. The CCBHC uses technology that has been certified to current criteria under the ONC Health IT Certification Program for the following required core set of certified health IT capabilities that align with key clinical practice and care delivery requirements for CCBHCs. (Reference Source: As of February 2023, current criteria are the 2015 Edition of health IT certification criteria, as updated according to the 2015 Edition Cures Update. Additional information about health IT products certified to these criteria is available on the Certified Health IT Product List (CHPL)). 1. Capture health information, including demographic information such as race, ethnicity, preferred language, sexual and gender identity, and disability status (as feasible). (Reference Source: United States Core Data for Interoperability (USCDI) standard at § 45 CFR 170.213 and “Demographics” criterion at § CFR 170.315(a)(5)). 2. At a minimum, support care coordination by sending and receiving summary of care records, as noted in Transitions of care criterion at § 170.315(b)(1). 3. Provide people receiving services with timely electronic access to view, download, or transmit their health information or to access their health information via an API using a personal health app of their choice. (Reference Source: Clinical decision support). 4. Provide evidence-based clinical decision support. (Reference Source: Application access – all data request” criterion at § 170.315(g)(9) and “Standardized API for patient and population services” criterion at § 170.315(g)(10)). 5. Conduct electronic prescribing (Reference Source: Electronic prescribing” criterion at § 170.215(b)(3)). D. The CCBHC will work with DCOs to ensure all steps are taken, including obtaining consent from people receiving services, to comply with privacy and confidentiality requirements. These include, but are not limited to, those of HIPAA and other federal and state laws, including patient privacy requirements specific to the care of minors, existing IT systems to support these activities when there is no targeted use of program funding, CCBHCs are encouraged to explore ways to support alignment with standards across data- driven activities. E. The CCBHC develops and implements a plan within two (2) years from CCBHC certification or submission of attestation to focus on ways to improve care coordination between the CCBHC and all DCOs using a health IT system. This plan includes information on how the CCBHC can support electronic health information exchange to improve care transition to and from the CCBHC using the health IT system they have in place or are implementing for transitions of care. To support integrated evaluation planning, treatment, and care coordination, the CCBHC works with DCOs to integrate clinically relevant treatment records generated by the DCO for people receiving CCBHC services and incorporates them into the CCBHC health record. Further, all clinically relevant treatment records maintained by the CCBHC are available to DCOs within the confines of federal and/or state laws governing sharing of health records. F. The CCBHC must participate with the MHA’s HIE (HIE) and be capable of exchanging protected health information, connecting to inpatient and ambulatory electronic health records (EHRs), connecting to care coordination information technology system records, and supporting secure messaging or electronic querying between providers, and patients. This requirement must include but is not limited to using the HIEs for admission, discharge, and transfer (ADT) data and closing referral loops for social determinants of health (SDOH). 1. The CCBHC must support and facilitate its subcontractors or DCOs exchange of data with the MHA’s HIE. 2. The Contractor must require its subcontractors or DCOs to provide ADT data to the MHA’s HIE. 3. The CCBHC must submit annually, the following: (a) A HIE Participation Report to Department of Mental Health providing the number and percentage of subcontractors or DCOs connected to the HIE and the type of participation. (b) CCBHC’s plan to support use of HIEs (HIE Subcontractor/DCO Support Plan), including, but not limited to, collaborative CCBHC’s efforts that facilitate and support consistent and accurate data submission from subcontractors/DCOs to the HIEs. G. The CCBHC’s information system must support the use of HIEs and EHRs necessary for near real-time understanding of member needs and reporting metrics, such as electronic clinical quality measures (eCQMs).