Performance Management

The Health Home Performance Management Program (PM) provides a formal framework for Health Homes, Care Management Agencies, Managed Care Plans and the State to work together to improve health outcomes of Health Home members.

Successful PM requires concerted and tactical efforts by Lead Health Homes to actively monitor performance measures and manage practices, processes and providers to ensure Health Home care management is providing value and improving health outcomes.

All Quality Measures are reported to CMS on an annual basis. All Process Measures are utilized to assess Health Home and Care Management Agency´s quality of care. The PM Program includes but is not limited to individualized technical assistance, learning collaboratives, redesignation support and quality/performance improvement webinars and activities.

Health Home Performance Measure Documents

In 2013, the Center for Medicaid and CHIP Services (CMS) recommended a core set of health care quality measures.

The Health Home Core Set Manual identifies the technical specification and resources required for data collection and reporting.

The State Plan Amendment identifies a set of Quality Measures that falls within three categories: Clinical Outcomes, Experience of Care and Quality of Care.

The Health Home Care Management Assessment Reporting Tool (HH-CMART) is a tool for the collection of standardized care management data for members in outreach or enrolled in a Health Home. The data will provide the Department of Health (DOH) with information about care management services to evaluate the volume and type of interventions and the impact care management services have on outcomes for people receiving these services. The data requirements include submission of specified data about care management services provided to members in Health Homes. The submission file will include information for all Medicaid members involved in Health Home care management programs during the reporting period.

CMART Specification Documents:

Social Determinants of Health being incorporated into CMART 3.7:

HH-CMART Reporting Periods and File Submission Dates

Reporting Period Due Date Last Date to Submit Revisions
First Quarter 2022 (January - March) 1st Monday in May May 31st
Second Quarter 2022 (April -June) 1st Monday in August August 31st
Third Quarter 2022 (July - September) 1st Monday in November November 30th
Fourth Quarter 2021 (October - December) 1st Monday in February February 28th (29th in Leap Years)

NYS DOH and Salient HHS jointly developed the MAPP dashboards to support the Health Home provider community with program oversight and performance management. The dashboards provide actionable data to help improve the goals of the Health Home program.

The Salient Health Home Dashboards include utilization and enrollment data from New York State Medicaid paid fee-for-service claims and managed care encounters, as well as from the Health Home Tracking System. The major source of the Health Home data is the Health Home Tracking System (input by the Health Home provider system), with the claims, encounters and dollars coming from the Medicaid Data Warehouse. The dashboards are updated monthly with new data.

The dashboards use Health Home tracking data and visit counts dating back to January 1, 2012, which was the start of the Health Home program. In the first few months, the data are attributed to "legacy programs," i.e., Health Homes covered from prior Therapeutic Case Management (TCM) programs.

You must be both a Health Commerce System (HCS) and MAPP User to access the MAPP Dashboards.

What is Re-Designation?

After the initial three year period of designation, DOH is required to review Health Home performance to determine whether Health Homes should be approved to operate beyond the initial three year designation period. The Department and its State Agency Partners (Office of Mental Health, AIDS Institute, and Office of Alcoholism and Substance Abuse Services) will conduct a collaborative review to determine whether Health Homes across the State are in compliance with Health Home standards and requirements.

Re-Designation of Health Homes will be determined based on:

  • Compliance with Federal and State standards and requirements
  • Health Home goals to reduce preventable hospitalizations and emergency room visits, and avoid unnecessary care
  • Governance and operational integrity
  • Evidence of positive interventions, integration of care and improved outcomes for members
  • Ability to develop capacity and capabilities to fully participate in the Behavioral Health integration, DSRIP and other state initiatives

Health Home Re-Designation Site Visit Standards and Chart Review Tools

  • Health Homes De-designation Policy #HH0015 - (Web) - (PDF) - Effective August 1, 2023
  • Health Homes Redesignation Policy #HH0014 - (Web) - (PDF) - Updated February 21, 2024 (retroactive to August 1, 2023)
    • Health Home Redesignation Policy #HH0014 - Guide to Edits - (PDF) - February 2024
  • Comprehensive Guide to the Health Home Redesignation Process - (Protected Excel) - February 2024
  • State Authority for Health Home Designation and Ongoing Oversight - (PDF)

HARP Quarterly Progress Reports


The following documents represent the versions of the FACT-GP and the Health Home Functional Assessment that were used by each Health Home at enrollment, annually and at discharge.

The FACT-GP and Functional Assessment does not take the place of the comprehensive assessment that should be done on each enrollee. They do allow the department to collect basic information about the members in the health home in order to adjust risk scoring and to measure longitudinal changes in this population.

The required languages are provided in both instruments. Instructions are included to explain the scoring of the tool. One can either do one's own scoring or can use a scoring sheet that automatically scores the tools. The department recommends use of the latter scoring sheet to reduce mathematical errors. The results of these instruments will be reported on the Health Home CMART which will be posted shortly.


*Please note: There are two Chinese versions of the FACT-GP and Health Home Functional Assessment - Simplified (MCHI) and Traditional (TCHI). The Simplified version is used in China, Malaysia and Singapore, and the Traditional version is used in Hong Kong and Taiwan. Users should ask respondents which version they would prefer.

Health Home Functional Questionnaire

Scoring for the FACT-GP and Health Home Functional Questionnaire

FACT-GP and Health Home Questionnaire Scoring Sheet

Health Home Re-Designation Site Visit Standards and Chart Review Tools