Health Home Plus Program Guidance for Individuals with HIV

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(Issued May 2018, revised April 2024)

Description

Health Home Plus (HH+) is an intensive care management program established to provide Health Home (HH) members the intensive services needed to stabilize their health and social service needs in the community. Health Home Plus (HH+) supports persons living with HIV (PLWH) by addressing barriers to positive health outcomes, adhering to HIV care and treatment, and achieving viral suppression. To ensure the intensive needs of Health Home Plus (HH+) individuals are met, Health Homes must assure these individuals receive a level of service consistent with the requirements for caseload ratios, face-to-face visits, and minimum levels of staff experience and education outlined below. The New York State Department of Health (NYSDOH) expanded training the eligible Health Home Plus (HH+) target population to include individuals who are HIV+ and virally unsuppressed.1

The Governor's EtE Initiative and the Health Home Model

In June 2014, the Governor announced his three-part initiative to end the HIV epidemic (EtE) in New York State by the end of 2020. Among the policy and program innovations that have resulted from EtE is the imperative that HIV treatment target viral load suppression as the clinical gold standard for improving the lives of individuals living with HIV and for preventing new viral transmission.

It is also recognized that social and behavioral factors contribute significantly to the inability of HIV+ individuals to remain engaged in the healthcare system and to achieve viral load suppression.  This is especially true for individuals with co-occurring conditions of Serious Mental Illness (SMI), Substance Use Disorder (SUD), or homelessness.

The HH+ Program for individuals with HIV is intended to align the EtE Initiative's objective to achieve viral suppression with the Health Home model of care. By recognizing HIV+ individuals with detectable viral load and those encountering phyco-social barriers to achieving viral suppression warrant the highest intensity of care, the expanded HH+ program will support PLWH achieve viral load suppression and address barriers to maintaining h4alth and adhering to care and treatment.

Eligible Populations

This guidance applies to the Health Home Plus (HH+) categories of care provided to Health Home members receiving care management service. These include individuals who are HIV+,

AND:

  1. Not virally suppressed (Viral load > 200 copies per mL), OR
  2. Have behavioral health conditions (SMI, and/or engage in Intravenous Drug Use) regardless of viral load status; AND
    • Had three or more in-patient hospitalizations within the last 12 months; OR
    • Four or more Emergency Room visits in the within the last 12 months; OR
    • Involvement with criminal justice system(s), including release from incarceration (jail, prison) within the past year; OR
    • Homelessness at time of eligibility (Housing Urban Development's [HUD] Category One (1 nighttime) homeless definition-An individual who lacks a fixed, regular, and adequate residence):
      • has a primary nighttime residence that is a public or private place not meant for human habitation, such as:
        • a car, park, sidewalk, abandoned building, bus or train station, airport, or camping ground; is living in a publicly or privately-v shelter designated to provide temporary living arrangements (including hotels and motels paid for by Federal, State, or local government programs for low-income individuals or by charitable organizations, congregate shelters, and transitional housing); or an institution where one resided for 90 days or less.
  3. Clinical Discretion: Managed Care Organizations (MCOs) coordinate physical and behavioral health services for individual members. MCOs, including mainstream plans, HIV-SNPs and HARPs; - and medical providers are responsible for ensuring that high need members have positive health outcomes and receive needed services. MCOs and medical providers have Clinical Discretion to:
    • Refer individuals into the Health Home Plus (HH+) Category.

For medical providers, there's no standard template for clinical discretion, but clinical discretion requests from providers must include:

  • Status of an individual's viral load, AND
  • Factors that indicate the need for referral into Health Home Plus (HH+) or a continuation of services such as: newly diagnosed HIV status, viral load suppression is not stable, housing instabilities, poor adherence to treatment plan, etc.

It is common for individuals who have recently become unsuppressed to need continued intensive support to ensure ongoing suppression; examples include a history of adherence issues, current instability with housing, chaotic substance use, or newly diagnosed status.

Members who are Eligible for AIDS Institute (AI) and Office of Mental Health (OMH) Health Home Plus (HH+)

CMA supervisors and care managers/coordinators should determine the most appropriate Health Home Plus (HH+) assignment for a member who is diagnosed with serious mental illness (SMI) and HIV. Members who are eligible for both HIV and SMI Health Home Plus (HH+) should be served at a level of intensity consistent with the requirements of HH+.

When working with a member who meets the eligibility criteria for both SMI and HIV HH+, a determination must be made by the health home/care management agency regarding the most appropriate care management program that will best serve the member's needs while also respecting member choice.

The care manager supervisor, care manager, and the member must evaluate what the most pressing concerns are for this member and the root cause of their instability. The Plan of Care should address the dual needs of the member. If the person is virally unsuppressed, the need to work toward adherence to care and treatment (medication) is a priority. If the person's SMI is not controlled, then this too must be a priority. In such cases, supervisory staff must review the needs, review the plan of care, and ensure that the medical and mental health providers are contacted and include the care manager and member in the conversation about what the most appropriate CMA would be. The care manager supervisor must actively work with the care manager to ensure that the needs of the member are being appropriately addressed.

Care Management Agencies (CMAs)) Eligible to Serve Health Home Plus (HH+) Individuals/Provider Qualifications

All legacy COBRA HIV Targeted Case Management (TCM) is eligible to provide Health Home Plus (HH+) care management services and bill the Health Home Plus (HH+) rate. The Lead Health Homes must attest that the Care Management Agency (CMA) is compliant with all staffing qualifications, case load size guidance, and training requirements.

Care Management Agencies (CMAs) that are non-legacy providers may qualify for providing Health Home Plus (HH+) HIV care management services and bill the Health Home Plus (HH+) rate if they can attest to the following agency qualifications:

  • Article 28 or Article 31 provider, certified home health agency, community health center, community service program, or other community-based organization with:
    • Two years' experience in the case management of persons living with HIV or AIDS; OR
    • Three years' experience providing community-based social services to persons living with HIV or AIDS; OR
    • Three years' experience providing case management or community-based social services to women, children, and families; substance users; Mentally Ill Chemical Abuser (MICA) clients; homeless persons; adolescents; parolees, recently incarcerated; and other high-risk populations and includes one year of HIV related experience.

Attestation

Prior to billing for Health Home Plus (HH+) services, Lead Health Homes are responsible for submitting written attestation of all contracted Care Management Agencies (CMAs) who will provide Health Home Plus (HH+) for members who are HIV+ and meet credentials, staff qualifications, core competencies or annual trainings. Health Homes must have formal policies and procedures in place for ensuring such credentials are current at the time of Health Home Plus (HH+) service delivery.

Staff Qualifications

All legacy and non-legacy Care Management Agencies (CMAs) who qualify for Health Home Plus (HH+) HIV services and rates must attest that the Health Home Plus (HH+) staff meets the following minimum qualifications and training requirements:

  • Care Management Supervisor: Minimum qualifications
    • Master's degree in Health, Human Services, Mental Health, Social Work and one year of supervisory experience and one year of qualifying experience** OR
    • Bachelor's degree in Health, Human Services, Mental Health, Social Work and two years of supervisory experience and three years of qualifying experience**.
  • Care Manager/Coordinator: Minimum qualifications
    • Master's or Bachelor's degree in Health, Human Services, Education, Social Work, Mental Health and one year of qualifying experience** OR
    • Associates degree in Health, Human Services, Social Work, Mental Health, or certification as an R.N. or L.P.N. and two years of qualifying experience**.
  • Navigator/Community Health Worker/Peer: Minimum qualifications
    • Ability to read, write, and carry out directions AND
    • High School Diploma or GED, OR
    • Certified Alcohol and Substance Abuse Counselor (CASAC), OR
    • Certification as a Peer (AIDS Institute Peer Certification preferred), OR
    • Community Health Worker

In rare circumstances, staff may have unique education and/or experience to adequately serve the Health Home Plus (HH+) HIV population but do not meet the qualifications outlined above. Health Home (HH) Care Management Agencies (CMAs) may apply for a waiver for such staff. Waivers are not intended to be the sole approach for an agency looking to expand capacity in serving the Health Home Plus (HH+) HIV population. Agencies should be prudent in selecting staff to pursue a waiver of qualifications, and only be submitted for those staff whose unique qualifications allow them to adequately serve the population.

For staff waiver requests, please contact the New York State Department of Health (NYSDOH) AIDS Institute at HIVCareMgt@health.ny.gov.

Qualifying Experience**: means verifiable work with the target populations defined as individuals with HIV, history of mental illness, homelessness, or substance use disorder.

Note: Staff serving Health Home Plus (HH+) populations should also demonstrate knowledge of community resources, sensitivity towards the target population, cultural competence, and speak the language of the community.

Program Requirements

Program requirements for Health Home Plus (HH+) members are to be carried out consistent with the existing "Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations" guidance distributed by the Department of Health.

General Requirements:
  • Health Home Plus (HH+) members may stay in the program a maximum of 12 months.
  • In cases where extenuating circumstances are documented, and written justification provided; an extension may be granted for recipients to remain in the program an additional 12 months.
Case Load Ratio:
  • The required caseload ratio for Health Home Plus (HH+) members shall be one (1) full-time employee to a maximum of 15-20 Health Home Plus (HH+) recipients.
  • If the program implements a team model (team is defined as one (1) care manager/coordinator and peers/navigators/community health worker), then the case load may increase by 10 for each additional team member.
  • One (1) care manager/coordinator may supervise no more than two team members.
Contact Frequency:
  • A minimum of four (4) core services must be provided per month:
    • At least two (2) of the four (4) core services must be face-to-face contacts.
    • At least one (1) face-to-face contact per month must be with the care manager/coordinator.
  • Face-to-Face visits should occur at:
    • Assessment.
    • Reassessment at six months
    • Plan of care revisions/update (every 6 months, or before based on the needs of the client).
  • Case conference with all providers and the client must occur every six months, or as needed based on the needs of the client.
  • If contact frequencies have not been met, then the CMA may bill for core services at the High-Risk rate for that month. The HH+ rate code can be billed only when this requirement is met and clearly documented in the individual's record.

Staff Training Requirements

Care manager/coordinator and peers/navigators/community health worker staff serving individuals in Health Home Plus (HH+) must meet training requirements established by the AIDS Institute.

Training requirements include:

  • All core competency content areas completed within the first 18 months of employment, AND
  • A minimum of 40 hours annually thereafter.

Note: Child Abuse and Neglect (Mandated Reporting) and HIV Disclosure/Confidentiality must be completed annually.

Core Competency Content Areas

Core Competency content areas listed below are intended to serve as a training resource guide for all Health Home staff who work with individuals living with HIV. Some webinars have been offered as live webinars, where there is conversation with participants and live Q&A, while others are pre-recorded webinars or online courses.

Supervisors should use discretion, look for trainings that addresses the below core competency content areas, and choose the format that best fits the needs of individual staff.

Core Competency Training Content Areas

  • The Role of Health Home Care Managers in Improving Health Outcomes for People Living with HIV/AIDS or At Risk For HIV**
  • Intro to Co-occurring Disorders for Client with HIV/AIDS
  • Intro to HIV, STI's, and HCV
  • Harm Reduction
  • Overview of HIV Infection and AIDS
  • Lesbian, Gay, Bisexual Transgender, Queer, Intersex, and Asexual (LGBTQIA+) Cultural Competency
  • Primary Care and Treatment Adherence for HIV Positive Individuals
  • Role of Non-clinicians in Promoting PrEP/PEP
  • Sexual Orientation and Gender Identity (SOGI)**
  • Ending the Epidemic
  • HIV/AIDS and Adolescents
  • Sexual Health
  • Substance Use Disorder (SUD)/ Drug User health
  • Transgender Health

Supervisors: The training resources listed below provide online/WebEx/Zoom trainings that address a wide range of topics including HIV, sexual health, LGBTQIA+, mental health, substance use, etc. Contact each training resource directly to get on their email listservs.

Please, check the content of each training to assist your staff in registering for training that is appropriate for their needs and AI requirements.

**Trainings that are required annually.

Training Resources:

Care Management Models That Meet Health Home Plus (HH+) Requirements

To meet the changing and complex needs of the Health Home Plus (HH+) population, Care Management Agencies (CMAs) may utilize different models of care management to achieve successful transitions, continuity of care, and improved outcomes. Care Management Agencies (CMAs) have the option to adopt any of the following models of care management listed below. To ensure Health Home Plus (HH+) recipients on a given caseload receive the required level of services, the noted case load limits will apply.

Health Home Plus (HH+) Only Caseload (caseload comprised only of individuals with HH+ levels of need)

MODEL 1: Health Home Plus (HH+) with Care Manager Only

  • One (1) Health Home care manager/coordinator - maximum case load of 15-20 members.
MODEL 2: Health Home Plus (HH+) with Care Management Team
  • One (1) Health Home care manager/coordinator plus one (1) peer/navigator/community health worker - maximum case load of 25-30 members.
  • One (1) Health Home care manager/coordinator plus two (2) peer/navigator/community health worker - maximum case load of 35-40 members.
  • One care manager/coordinator may supervise no more than two team members.
Mixed Caseloads (caseload comprised of Health Home Plus (HH+) and non- Health Home Plus (HH+) individuals)

Mixed Caseloads : Care Managers may have a mixed case load. To allow flexibility, medium or low acuity members may be part of a HEALTH HOME PLUS (HH+) case load, especially at the beginning of forming HEALTH HOME PLUS (HH+) caseloads and teams, in rural areas where fewer cases occur, or as members move to stability but need continuity of care.

  • One (1) Health Home care manager/coordinator with ten (10) or more Health Home Plus (HH+) members - max caseload 40 members (inclusive of HH+ members).

Note: When the number of Health Home Plus (HH+) clients is extremely low, the care manager supervisor should use discretion to build an appropriately sized caseload. Example: if a CMA has only 3 members eligible for Health Home Plus (HH+), the care manager supervisor can work with the care manager to build a caseload that does not exceed New York State Department of Health (NYSDOH) caseload limits and allows for the HH+ members to receive the necessary intensive level of services.

For technical assistance with caseloads, please contact the New York State Department of Health (NYSDOH) AIDS Institute at HIVCareMgt@health.ny.gov.

Referral for Health Home Plus

Referrals can come from multiple sources including community providers, behavioral health providers, MCOs, hospitals or other healthcare providers. The referral source can supply documentation verifying that the individual meets the requirements for Health Home Plus (HH+) services. Once a referral is received by the Health Home Network, the Health Home Lead must ensure the individual is promptly assigned to a CMA qualified to serve the Health Home Plus (HH+) population.

Billing and Tracking System

The differential monthly rate for Health Home Plus (HH+) is higher compared to the Health Home High Risk/Need Care Management and Health Home Care Management rates and is intended to appropriately reimburse for the intense and consistent support needed for this population.

  • The unique rate code for Health Home Plus (HH+) services is 1853.
  • Health Home Plus (HH+) payment rates for Downstate and Upstate are noted in the table below.
Rate Code Rate Description (HIV) HH+ Monthly HH+ Rate
1853

 Downstate (applicable to Dutchess, Putnam, Rockland, Westchester, Nassau and Suffolk Counties and New York City

 $800
Upstate (applicable to all counties other than Downstate) $750

Monitoring

The Department of Health (DOH) reserves the right to perform reviews of Health Homes to monitor compliance with the Health Home Plus (HH+) credential requirements outlined above. DOH and AIDS Institute maintain records of Health Home attestations. DOH will also evaluate performance for generating positive health outcomes for Health Home Plus (HH+) members.

Technical Assistance to Health Homes and Care Management Agencies
The AIDS Institute (AI) Health Home team provides Technical Assistance to Health Homes and Care Management Agencies (CMAs). The AI Health Home team can be reached at HIVCareMgt@health.ny.gov.