CareLink New Mexico (CLNM) Health Homes

What is a Health Home?

CareLink NM is a set of services authorized by section 2703 of the Patient Protection and Affordable Care Act (P.L. 11-148, ACA).  CareLink NM services are delivered through a designated provider agency (CareLink NM provider agency) to enhance the integration and the coordination of primary, acute, behavioral health, and long-term services and supports.  The CareLink NM provider agency assists a CareLink NM Member (CLNM Member) by engaging him or her through more direct relationships and intensive care coordination resulting in a Comprehensive Needs Assessment (CNA) and plan of care (CareLink NM Plan).  The provider agency also:

  • Increases access to health education and promotion activities;

  • Monitors the CLNM Member’s treatment outcomes and utilization of resources;

  • Coordinates appointments with primary care and specialty practitioners;

  • Shares information among his or her physical and behavioral health practitioners to reduce the duplication of services, actively manages the to transitions between services; and

  • Participates as appropriate in the development of the CLNM Member’s hospital discharge plan.

 

Who is eligible to participate in the CareLink NM Health Home?

  • Any individual who currently has Medicaid benefits under the Centennial Care Medicaid or fee-for-service Medicaid;

  • Any individual who has a Serious Mental Illness (SMI) diagnosis;

  • Any individual who has a Serious Emotional Disturbance (SED) diagnosis.

 

What are the six (6) core services of a Health Home?

Comprehensive Care Management

Comprehensive Care Management must include:

  • Assessment of preliminary risk conditions and health needs;

  • Development of CareLink NM Plans, which will include CLNM Members’ goals, preferences and optimal clinical outcomes and the identification of specific additional health screenings required based on the individual’s risk assessment;

  • Assignment of health team roles and responsibilities;

  • Development of treatment guidelines for health teams to follow across risk levels or health conditions;

  • Oversight of the implementation of CareLink NM Plans which bridge treatment and wellness support across behavioral health and primary care;

  • Monitoring of Members’ health status and service use to determine adherence to or variance from treatment guidelines and treatment plan goals and objectives through claims-based data sets and patient registries; and

  • Development and dissemination of reports that indicate progress toward meeting outcomes for clietn satisfactio, health status, service delivery and cost.

Care Coordination and Health Promotion

Care Coordination and health promotion services must include, but are not limited to:

  • Scheduling appointments;

  • Conducting face-to-face visits with Members’

  • Conducting referrals and follow-up monitoring;

  • Delivering health education specific to the CLNM Member’s chronic conditions;

  • Developing self-management plans with the CLNM Member;

  • Educating CLNM Members about the importance of immunizations and screening for overall general health;

  • Providing support for improving social networks; and

  • Providing health-promoting lifestyles interventions, including but not limited to: substance use prevention and/or reduction; resiliency and recovery, independent living, smoking prevention and cessation; nutritional counseling, obesity reduction and prevention and increasing physical activity.

Comprehensive Transitional Care

Comprehensive Transitional Care services must include but are not limited to:

  • Coordination of the CareLink NM Plan;

  • Participation in all discharge activities;

  • Implementing appropriate services and supports to reduce hospital admissions and readmissions;

  • Facilitating the transition to long term services and supports;

  • Interrupting patterns of frequent hospital emergency department use;

  • Collaborating with physicians, nurses, social workers, discharge planners, pharmacists, and others to continue implementation of the Care Link NM Plan or modify it as appropriate;

  • Enhancing CLNM Member’s, their family’s and other supports’ ability to manage care and live safely in the community; and

  • Increasing the use of proactive health promotion and self-management.

Individual and Family Support Services

Individual and Family Support Services must include but are not limited to:

  • Navigating the health care system to access needed services for CLNM Member and families;

  • Assisting with obtaining and adhering to medications and other prescribed treatments;

  • Identifying resources for individuals to support them in attaining their highest level of health and functioning in their families and in their community; and

  • Arranging for transportation to medically necessary services.

Referral to Community and Social Support Services

Referral to Community and Social Support Services must include but are not limited to:

  • Identifying available community-based resources such as legal services, housing, educational supports, employment supports, recovery and treatment plan goals support;

  • Actively managing appropriate referrals and access to care;

  • Providing engagement with other community and social supports; and

  • Following up with facilities post-engagement.

Use of Health Information Technology to Link Services

Use of Health Information Technology to Link Services must include but is not limited to:

  • Tracking of calls, referrals, and follow up;

  • Tracking of beneficiary’s CareLink NM opt in/opt out status and data sharing agreement related to the program;

  • Goals identified as a part of the CareLink NM Plan

  • Progress information related to identified health action goals and progress on CareLink NM Plan outcomes;

  • Changes in CareLink NM enrollment in Medicaid or CareLink NM;

  • Completing and monitoring Needs Assessments; and

  • Data collection to support quality indicators measuring program success.

 

MHR, Inc.

1100 W.21st

Clovis NM 88101

(575)769-2345