HEALTH HOMES

CLASSROOM MANUAL 2024

TABLE OF CONTENTS

Manual Section Title Page #

Table of Contents 1-3

A: Health Home Health Home Services
Services 4
Health Home Care Coordinator's Checklist 8
Health Home Tiers for Billing 9
Health Home Care Coordination Documentation Guide 16
Guidelines for HH Staff Roles & Responsibilities 29
Health Home Consent Form Guidance 32
B. Activities, Foster Child PRISM Eligibility Screen
Vignettes & HAP
Examples 37
PRISM Health Report for John Doe 38
Client Vignettes 41
PRISM Screens 48
Jordan Larson HAP 66
Robert Smith HAP 73
C. Assessment & Katz Index of Independence in Activities of Daily Living
Screening Tools 80
Link to Katz Video 81
Depression Screening & Suicide Guide Sheet 82
Depression and the Patient Health Questionnaire (PHQ-
9) 85
Patient Health Questionnaire-9 (PHQ-9) 88
Body Mass Index (BMI) Table 89
BMI Calculator for Adults and Children 90
Alcohol Use Questions (AUDIT) & Guidelines for Scores 91
DAST-10 93
Guidelines for DAST Scores 95
Standard Drink Equivalents (NIH) 96
Wasbirt pic, GAD-7 97
My Falls Free Plan 98
Stay Independent: Are You at Risk? 99
Pain Intensity Instruments: Numeric Rating Scale 101
Pain Intensity Instruments: Wong-Baker Faces Pain
Rating Scale 102
FLACC Behavioral Pain Assessment Scale 103
Assessment Guide and Translations 104
1
 HEALTH HOMES
CLASSROOM MANUAL 2024
TABLE OF CONTENTS

D. Forms & Sample Telephone Outreach Script

Resources
110
Due Diligence 111
Motivational Interviewing (MI)- Decisional Balance Scale 112
MI - Importance, Confidence, Readiness Rulers 113
NEMT Request form 114
NEMT for Health Home Clients 115
NEMT for Health Home Clients FAQ 116
Residential Introduction Letter 118
Best Practices When Visiting a Residential Facility 119
Best Practices When Visiting a Skilled Nursing Facility 120
Overview of HCA Interpreter Services Program 121
Checking Eligibility in ProviderOne (P1) 123
PRISM - CARE field details 131
PRISM - Finding a Case Manager Contact Info 133
Advance Care Planning (ACP) Guide Sheet 135
Hospital to Home Discharge Guide 137
Discharge Preparation Checklist 145
WSHA Care Transitions Toolkit 148
Behavioral Health Treatment and Resources 151
BH-ASO fact sheet 153
Depression and Anxiety - SAMHSA 155
E. Official Forms & Goals Setting & Action Planning Worksheet (DSHS 10-
Documents 422) N/A
HAP Blank (DSHS 10-481) N/A
HAP Instructions (DSHS 10-481) N/A
Insignia Patient Activation Measure (PAM)
N/A
Insignia Caregiver Activation Measure (CAM) N/A
Insignia Parent of Patient Activation Measure (PPAM) N/A
Pediatric Symptom Checklist (PSC-17) (DSHS-10-509) N/A
Instructions for Scoring the Pediatric Symptom Checklist
(PSC-17) (DSHS-10-509 Instructions) N/A
HH Participation Authorization and Information Sharing
Consent (HCA 22-852) N/A
Health Home - Adolescent Information - Sharing
Consent (HCA 22-855) N/A
Release of Information (ROI) for Substance Use
Disorder Services (HCA 13-335) N/A

2
 HEALTH HOMES
CLASSROOM MANUAL 2024
TABLE OF CONTENTS

Health Home Participation Opt-Out/Decline Services

(HCA 22-853) N/A
Incident Report (HCA 22-813)
N/A
Apple Health Managed Care Service Area Map (HCA
19-0036) N/A
BH-ASO map (HCA 19-0040) N/A
Health Home Rack Card for Clients and Providers
(DSHS 22-1588) N/A

3
 Health Home Services

1. Comprehensive Care Management

Health Home Care Coordinators deliver comprehensive care management, primarily in person
with periodic follow-up. Care management services include state approved screens and
development of a person-centered Health Action Plan (HAP). Care Coordinators provide
continuity and coordination of care through face-to-face visits and telephonic support. Care
Coordinators assess beneficiary readiness for self-management and promote self-management
skills so the beneficiary is better able to engage with health and service providers. By working
with beneficiaries, Care Coordinators support the achievement of self-directed, person-
centered health goals designed to attain recovery, improve functional or health status, or
prevent or slow declines in functioning.

The initial HAP is developed in collaboration with the client and may include parents, family
members, caregivers, legal representatives, and other collaterals. The HAP establishes a long-
term goal, a short-term goal or goals, and action steps to achieve these goals.

Screens include clinical and functional screens, including depression, alcohol or substance use
disorder, functional impairment, falls risk, and pain, appropriate to the age and risk profile of
the beneficiary. Screens support referrals to services when needed such as specialty care and
and/or long-term services and supports. The beneficiary’s activation level is reassessed at least
once during each four-month activity period while receiving health home services.

Other screens and assessments that may supplement comprehensive care management are
Medicaid managed care organizations’ contractually required health risk assessments for
beneficiaries with special health care needs, mental health treatment plans, substance use
disorder treatment plans, and/or other pre-existing care plans.

Care Coordinators offer beneficiaries the opportunity to consider and discuss advance care
planning. The Care Coordinator may assist the beneficiary to access legal assistance to develop
advance directives.

Health Home services do not duplicate other services, such as case management. Care
Coordinators bridge the beneficiary’s services across multiple settings to ensure access and
coordination of needed medical, behavioral, and social support services.

2. Care Coordination

The Care Coordinator plays a central and active role in development and execution of cross-
system care coordination to assist the beneficiary to access and navigate needed services. Care

1
January 2018

4
Coordinators have the ability to accompany beneficiaries to health care appointments as
needed. The Care Coordinator fosters communication between care providers including
primary care providers, medical specialists, and entities authorizing behavioral health and Long
Term Services and Supports (LTSS). Care coordination bridges all of the beneficiary’s systems of
care, including non-clinical support such as food, housing, legal services, and transportation.

When providing intensive care coordination to the beneficiary, the Care Coordinator caseload is
maintained at a level that ensures fidelity in providing required health home services.
Community Health Workers, peer counselors, wellness or health coaches, and other non-clinical
staff are used to provide outreach, engagement, and support under the direction and
supervision of the Care Coordinator.

Care coordination shall provide informed interventions that recognize and are tailored for the
medical, social, economic, behavioral health, functional impairment, cultural, and
environmental factors that impact a beneficiary’s health and health care choices. Joint office
visits by the beneficiary and the Care Coordinator with health care providers offer opportunities
for mentoring and modeling communication with providers. Care Coordinators may establish
multidisciplinary care teams or participate on an existing team. Their participation aids to
better coordinate services, identify and address gaps in care, and ensure cross-systems
coordination to ensure continuity of care.

Care Coordinators will promote:

1) optimal clinical outcomes, including a description of how progress toward outcomes will
be measured through the HAP;
2) outreach and engagement activities that support the beneficiary’s participation in their
care and promote continuity of care; and
3) use of peer supports, support groups, and self-care and self-management programs to
increase the beneficiary’s knowledge about their health conditions and improve
adherence to prescribed treatments and medications.

The HAP is reviewed and revised during each four-month activity period or as needed to
address the achievement of goals and action steps and changes in the client’s self-management
of their chronic conditions. Screening assessments are offered and administered during each
activity period.

3. Health Promotion

Health promotion begins for health home beneficiaries with the commencement of the HAP.
Health education and coaching is designed to assist beneficiaries to increase self-management
skills and improve health outcomes. Each Washington health home must demonstrate use of
self-management, recovery, and resiliency principles using person-centered supports including
family members and paid and unpaid caregivers. The Care Coordinator uses the beneficiary’s
activation score and level to determine the coaching methodology for each beneficiary to

2
January 2018

5
develop a teaching and support plan. Educational materials are customized and introduced
according to the beneficiary’s readiness for change and progress with a beneficiary’s level of
confidence and self-management abilities. The health home will provide wellness and
prevention education specific to the beneficiary’s chronic conditions and HAP. Health
promotion and education includes assessment of need, facilitation of routine and preventive
care, support for improving social connections to community networks, and linking
beneficiaries with resources that support a health promoting lifestyle. Linkages include but are
not limited to resources for smoking prevention and cessation, substance use disorder
prevention, nutritional counseling, obesity prevention and reduction, physical activity, disease
specific or chronic care management, self-help resources, and other services. Health promotion
and education may also occur with parents, family members, caregivers, legal representatives,
and other collaterals to support the beneficiary in achieving improved health outcomes.

4. Comprehensive Transitional Care

Comprehensive transitional care is provided to prevent beneficiary avoidable readmission after

discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing,
substance use disorder treatment, or residential habilitation setting) and to ensure proper and
timely follow-up care.

The beneficiary’s HAP includes transitional care planning. Transitional care planning includes:

1) A notification system with managed care plans, hospitals, nursing facilities, and
residential/rehabilitation facilities to provide the health home prompt communication
of a beneficiary’s admission and/or discharge from an emergency department, inpatient
facility, skilled nursing or residential/rehabilitation facility, and with proper, permissions,
a substance use disorder treatment setting. Progress notes or a case file will document
the notification. The HAP is updated as a part of transition planning.

2) Active participation of the Care Coordinator in all phases of care transition including:
discharge planning visits during hospitalizations or nursing facility stays, post discharge
face-to-face visits, and telephone calls.

3) Beneficiary education to support discharge care needs including: medication

management, follow-up care, and self-management of chronic or acute conditions.
Information on when to seek medical care and emergency care is also provided.
Involvement of formal or informal caregivers is facilitated when requested by the
beneficiary.

4) A systematic follow-up protocol to assure timely access to follow-up care post

discharge and to identify and re-engage beneficiaries that do not receive post discharge
care.

3
January 2018

6
 5) Medication reconciliation prior to or soon following discharge to the community or
other setting.

5. Individual and Family Support

The Care Coordinator recognizes the unique role the beneficiary may give family members,
identified decision makers, and caregivers in assisting the beneficiary to access and navigate the
health care and social service delivery system as well as support health action planning.

Peer supports, support groups, and self-management programs are used by the Care
Coordinator to increase beneficiary and caregiver knowledge of the beneficiary’s chronic
conditions, promote the beneficiary’s engagement and self-management capabilities, and help
the beneficiary improve adherence to their prescribed treatment.

The Care Coordinator will:

1) identify the role that parents, family members, informal supports, and paid caregivers
provide to the beneficiary to achieve self-management and optimal levels of physical
and cognitive function;
2) educate and support self-management, self-help, and recovery by accessing other
resources necessary for the beneficiary, their family, and their caregivers;
3) discuss advance care planning with beneficiaries and their families;
4) communicate and share information with beneficiaries, their families, and their
caregivers with appropriate consideration of language, activation level, literacy, and
cultural preferences.

6. Referral to community and social support services

The Care Coordinator identifies available community based resources and actively manages
referrals. They assist the beneficiary in advocating for access to care and promote engagement
with community and social supports related to goal achievement documented in the HAP.
When needed and not provided through other case management systems, the Care
Coordinator provides assistance to obtain and maintain eligibility for health care services,
Medicaid, disability benefits, housing, personal needs, and legal services. These services are
coordinated with appropriate departments of local, state, and federal governments, and
community based organizations. Referral to community and social support services includes
LTSS, mental health, substance use disorder, and other community and social service support
providers needed to support the beneficiary in achieving health action goals.

The Care Coordinator documents referrals to and access by the beneficiary of community and
other social support services.

4
January 2018

7
 HEALTH HOME CARE COORDINATOR’S CHECKLIST
Health Home Care Coordinator’s Checklist
 Receive assigned client from the Lead Organization
 Review assigned client in PRISM and other records and databases
 Contact client to engage in Health Home Services and arrange first face-to-face visit
• Fill out referral for Non-Emergency Medical Transportation and submit to local
Medicaid broker if client needs transportation to meet outside of residence to
participate in the program
 Provide Tier 1 services with a face-to-face visit to develop the initial Health Action Plan (HAP)
• Administer required screening
• Administer optional screenings as indicated
• Obtain signature on the Participation Authorization and Information Sharing Consent
form and other specialized releases as needed
• Discuss advance care planning with client and/or family (must be completed within
first year of engagement)
• Establish long term goal and short term goal(s) with associated action steps
 Establish follow up plan with the client, family, caregiver, and other health and social service
providers as indicated on the HAP. Complete face-to-face, telephonic, or other contacts as
needed.
 Provide ongoing Tier Two or Tier Three Health Home Services according to the HAP each
month as appropriate and document contact(s) and service(s) provided:
• Comprehensive Care Management
• Care Coordination
• Transitional Care Services with each in patient admission or emergency department
visit
• Individual and Family Support
• Referral to Community and Social Support Services
• Health Promotion
 Update HAP at least every trimester (four-month activity period) and more frequently
as needed and administer required and optional screenings
 Review documentation by allied staff (e.g. Peer Support Specialists, Wellness Coaches,
Community Connectors, Community Health Workers, etc.) to determine if revisions are needed
to the HAP. Consult with client as needed to review and revise the HAP.
 Educate client, family, and other collaterals about eligibility for the Advanced Home Care Aide
Specialist Pilot or the Community Integration in Adult Family Home Program and assist with
accessing these special benefits. Document collaboration with appropriate case managers.
 Participate on or organize a multidisciplinary care team and coordinate meetings as needed
 Complete comprehensive transitional care activities following in-patient admission or
emergency department care

January 2018
8
Health Home Tiers for Billing
Washington State Health Homes have designated three tiers that define the level of care coordination
services provided:

1. Initial engagement and health action plan. (HAP) completion = Tier One
2. Intensive level of care coordination = Tier Two
3. Low level of care coordination = Tier Three

The Tier Level of the client is intended to reflect the overall level of:
1. Engagement and activation level of the client and/or their caregivers
2. Activity in the Health Action Plan
3. Provision of at least one of the qualified Health Home services
4. Frequency of contacts (face-to-face visits, phone calls, referrals, or care coordination).

Selecting the appropriate Tier should most closely reflect the above activities. Typically the Tier will not
change from month to month, between Tier Two and Tier Three, but does change when the client and/or
their caregivers consistently demonstrate an intensive or low level Health Home need. At least one of the
six qualifying Health Home services must be provided within each Tier Level in order to bill and receive
payment for the service.

Qualifying Health Home services include;

 Comprehensive Care Management: The initial and ongoing assessment and care management
services aimed at the integration of physical, behavioral health, long-term services and supports,
and community services, using a detailed person-centered HAP which addresses all clinical and
non-clinical needs.
Examples:
o Conduct outreach and engagement activities
o Develop the HAP setting client centered goals and action steps to achieve the goals
o Complete comprehensive needs assessment such as the Patient Activation Measure
(PAM) and other required assessments for the HAP
o Prepare crisis intervention and resiliency plans
o Support the client to live in the setting of their choice
o Identify possible gaps in services and secure needed supports
 Care Coordination and Health Promotion: Facilitating access to, and monitoring of progress
toward goals identified in the HAP to manage chronic conditions for optimal health and to
promote wellness. Accomplished through face-to-face and collateral contacts with the client,
family, caregivers, physical care, and other providers.
Examples:
o Support to implement the HAP
o Encourage and monitor progress towards individualized short and long term goals
o Coordinate with service providers, case managers, and health plans
o Conduct or participate in interdisciplinary teams
o Assist and support the client with scheduling health appointments and accompany if
needed
o Communicate and consult with all providers and the client
o Provide individualized educational materials according to the needs and goals of the
client

February 2020

9
 o Promote participation in community educational and support groups
 Comprehensive Transitional Care: The facilitation of services for the client, family, and
caregivers when the client is transitioning between levels of care.
Examples:
o Follow-up with hospitals/ED upon notification of admission or discharge
o Provide post-discharge contact with client, family, and caregivers to ensure discharge
orders are understood and acted upon
o Assist with access to needed services or equipment and ensure it is received
o Provide education to the client and providers that are located at the setting from which
the person is transitioning
o Communicate and coordinate with the client, family, caregivers, and providers to ensure
smooth transitions to new settings
o Ensure follow-up with Primary Care Provider (PCP)
o Review and verify medication reconciliation post discharge is completed
 Individual and Family Supports: Coordination of information and services to support the client
and their family or caregivers to maintain and promote quality of life, with particular focus on
community living options.
Examples:
o Provide education and support of self-advocacy including referral to Peer Support
specialists
o Identify and access resources to assist client and family supports in finding, retaining and
improving self-management, socialization, and adaptive skills
o Educate client, family or caregivers of advance directives, client rights, and health care
issues
o Communicate and share information with the client, family, and caregivers with
appropriate consideration of language, activation level, literacy and cultural preferences
 Referral to Community and Social Supports: The provision of information and assistance for
the purpose of referring the client and their family or caregivers to community based resources as
needed.
Examples:
o Identify, refer and facilitate access to relevant community and social services that support
the client’s HAP
o Assist the client to apply for or maintain eligibility for health care services, disability
benefits, housing, and legal services not provided though other case management systems
o Monitor and follow-up with referral resources to ensure appointments and other activities
were established and the client engaged in the services
• Use of Health Information Technology to link services: Determine level of service provided
and update client health records and HAP according to the Health Home Qualified Lead required
information systems.

The descriptions below of each Tier Level are to be used as a guide when selecting the Health Home Tier.

Tier One – Outreach, Engagement and Health Action Plan (HAP) Development
 Lead Entity assigns an eligible client to a Care Coordination Organizations (CCO) using PRISM
information or other data systems to match the client to the CCO which will provide the Health
Homes services and outreach begins.

February 2020

10
 a. The CCO assigns the client to a Care Coordinator who completes a preliminary
assessment of the client’s Health Home needs, based upon known health and other risk
factors.
b. Contact is made with the client to arrange a face-to-face meeting to confirm the client’s
desire to participate in the Health Home Program.
c. Together, the Care Coordinator and the client identify the client’s health goals (long term
and short term) and develop the HAP.
d. The client ’s Health Action Plan shall provide evidence of:
1. Chronic conditions, severity factors and gaps in care, the client ’s activation
level, and opportunities for potentially avoidable emergency department visits,
inpatient hospitalizations and institutional placement;
2. Client self-identified goals, needed interventions or action steps, transitional care
planning, supports and interventions; and
3. Use of self-management, recovery and resiliency principles using person-
identified supports, including family members, and paid and non-paid caregivers.
 Once the client agrees to participate in the Health Home program and the HAP is developed, a
Tier One claim using procedure code G9148 may be submitted for payment. The Tier One
payment will only be paid once in a client’s lifetime to a lead entity for each enrolled and
engaged client.

Tier Two - Intensive Health Home Care Coordination

 Intensive Health Home care coordination is the highest level of care coordination. This level of
care coordination includes evidence that the Care Coordinator, the client and the client ’s
caregivers are actively engaged in the HAP, participating in activities that are in support of
improved health and well-being, have value for the client and caregivers, and support an active
level of care coordination through delivery of the Health Home services. Typically intensive
Health Home care coordination includes one face-to-face visit with the beneficiary every month
in which a qualified Health Home service is provided
o Exceptions can be approved to the monthly care coordinator’s face-to-face visit by the
Health Home Lead entity. A face-to-face visit with other service providers or allied staff
directly related to the client’s HAP goals and included in the action steps may be
considered as an exception.
o Exceptions can be approved to monthly care coordinator’s face-to-face visit by the
Health Home Lead entity as long as there is evidence of other types of qualifying health
home activities being provided.
 Document health home services provided in the client’s health record. Examples of services may
include:
a. Administration and follow up on clinical, functional, and resource use screenings,
including screens for depression, alcohol or substance use disorder, functional
impairment, and pain appropriate to the age and risk profile of the individual.
b. Continuity and coordination of care services through in-person visits, telephone calls and
team meetings, and the ability to accompany beneficiaries to health care provider
appointments, as needed.
c. Client assessments to determine readiness for self-management and promotion of self-
management skills so the client is better able to engage with health and service providers
and support the achievement of self-directed, individualized health goals designed to
attain recovery, improve functional or health status or prevent or slow declines in
functioning.

February 2020

11
 d. Fostering communication between the client and providers of care including the treating
primary care provider and medical specialists and entities authorizing behavioral health,
chemical dependency, developmental disability and long-term services and supports.
e. Promoting optimal clinical outcomes, including a description of how progress toward
outcomes will be measured through the HAP.
f. Health education and coaching designed to assist beneficiaries to increase self-
management skills and improve health outcomes.
g. Referrals and assessment of the use of peer supports, support groups and self-care/self-
management programs to increase the client’s knowledge about their health care
conditions and improve adherence to prescribed treatment.
 At least one of the six qualifying Health Home services must be provided during the month prior
to submitting a Tier Two claim using procedure code G9149 for payment.

Tier Three – Low Level Health Home Care Coordination

 Tier Three is selected when one of the situations described below matches the care coordination
needs of the client. Typically after the Tier One activity of establishing the HAP is completed a
client will move to the Tier Two level. In some cases, based on the preference of the client, and
their individual needs, they may move directly from Tier One to Tier Three. For example, a
client with an Activation Level of Four who is actively self-directing their care and needs
infrequent coaching to maintain their health.
 The Health Home Tier system was not designed to have beneficiaries changing Tiers month to
month based solely on the number or types of contacts. The movement to a Tier or between Tiers
is based on:
a. Engagement of the client and/or their caregivers;
b. Activity within the HAP;
c. Provision of at least one of the six qualifying Health Home services; and
d. Frequency of contacts (face-to-face visits, phone calls, referrals, or care coordination).
 The following situations describe when Tier Three (Low Level Care Coordination) would apply
for a client.
a. Low Level Health Home care coordination supports maintenance of the client’s self-
management skills with periodic home visits and/or telephone calls to reassess health care
needs.
b. The client expresses their preference to have fewer contacts or a lower level of
engagement with the care coordinator.
c. The client and the Care Coordinator identify that the client has achieved a sustainable
level of self-management for their primary chronic conditions.
d. Activity level supports a high level of activation and client demonstrates optimal self-
management and health promotion skills.
 At Tier Three the review of the HAP must occur at least every four months reviewing progress
towards goals, level of activation, and new or unidentified care opportunities.

 At least one of the six qualifying Health Home service must be provided prior to submitting a
Tier Three claim with procedure code G9150 for payment.

February 2020

12
Client Movement Between Tiers
 Based on the needs and preferences of the client they may move between Tiers Two and Three;
higher intensity to lower or lower intensity to higher.
 Examples of moving a client from Tier Two to Tier Three include:
a. The client’s Patient Activation Measure (PAM) score has stabilized over the past four
month period with optimal level of activation and HAP goals have been achieved.
b. The client’s PRISM risk score is under 1.0 for eight months and the client’s PAM Level
is at least a three.
c. A client has met their goals and is actively sustaining self-management activities.
d. The client has no new HAP goals to set or current issues to achieve requiring a higher
level of coordination, and has achieved and demonstrated self-management skills. Goals
may be modified or new goals added in collaboration by the client with the care
coordinator.
e. The client requests a lower level of care coordination.
f. The client was not available during the month and the care coordinator provided follow-
up care coordination with service providers or community resources.
 Examples of moving a client from Tier Three to Tier Two include:
a. An adverse health condition or new diagnosis resulting in increased emergency
department use, hospital admissions, readmissions, escalation or exacerbation of a
behavioral health or social concern.
b. The client expresses a desire to set a new HAP goal.
c. Environmental or psychosocial changes trigger a need for more intensive Health Home
services.
d. Life events trigger a need for higher Health Homes Services.

Unsuccessful Initial Outreach and Engagement:

 Some beneficiaries may not be successfully reached or engaged in Health Home services despite
multiple attempts to contact them in person, by phone, by mail, or through collateral contacts. In
these situations a Tier One claim for the engagement attempts cannot be submitted. The Care
Coordinator must consult with their organization for direction regarding policy and procedure for
engagement attempts and documentation of failed attempts to reach a client.
 When a client is not actively participating in the Health Home Program a claim cannot be
submitted to reflect the outreach attempts only.

REMEMBER: A qualifying Health Home service must be provided each month in order to submit a
claim for Tier Two or Tier Three payment.

February 2020

13
Tier Level Minimum Contact Activity Examples
Tier One Contact is made with the client to arrange Review PRISM and other available client
a face to face meeting to confirm the records
client’s desire to participate in the Health
Home Program. Administer required screenings.

Care Coordinator visits the client to Administer optional screenings as needed.

complete required assessments and
develop the Health Action Plan (HAP) with Together, the Care Coordinator and the
client centered goals and action steps to client identify the client’s health goals (long
achieve those goals. term and short term) and develop a Health
Action Plan (HAP).

Establish a follow up plan with the client.

Submit Tier One Claim for payment with

date of service when the HAP has been
completed.
Tier Two Typically intensive Health Home care Administration and follow up on clinical,
coordination includes one face-to-face functional, and resource use screenings
Intensive Health Home care visit with the beneficiary every month in
coordination which a qualified Health Home service is Continuity and coordination of care
provided. services through in-person visits,
telephone calls, and team meetings, and
Exceptions can be approved to the the ability to accompany beneficiaries to
monthly care coordinator’s face-to- health care provider appointments, as
face visit by the Health Home Lead needed.
entity. A face-to-face visit with other
service providers or allied staff directly Beneficiary assessments to determine
related to the client’s HAP goals and readiness for self-management and
included in the action steps may be promotion of self-management skills so
considered as an exception. the beneficiary is better able to engage
with health and service providers.
Exceptions can be approved to

February 2020

14
Tier Level Minimum Contact Activity Examples
monthly care coordinator’s face-to-face Health education and coaching designed
visit by the Health Home Lead entity as to assist beneficiaries to increase self-
long as there is documented evidence management skills and improve health
of other types of qualifying health home outcomes.
activities being provided.
Referrals and assessment of the use of
At least one qualifying Health Home peer supports, support groups and self-
service must be provided prior to care/self-management programs.
submitting a Tier Two claim for payment.
Medication reconciliation as part of care
transitioning.

Education and coaching of caregivers,

family members, and other supports.
Tier Three Low Level Health Home care coordination Monthly calls to the client to discuss
supports maintenance of the client’s self- success with maintaining health and/or
Low level Health Home care management skills with periodic home behavioral changes.
coordination visits and/or telephone calls to reassess
health care needs. Monthly call to check in on HAP progress
and to identify new or changing goals.
The client expresses their preference to
have fewer contacts or a lower level of At Tier Three the review of the HAP must
engagement with the care coordinator. occur at least every four months for
progress towards goals, level of activation,
Contact may not occur every month and new or unidentified care opportunities.
depending on the HAP and the needs of
the client.

At least one qualifying Health Home

Service must be provided prior to
submitting a Tier Three claim for payment.

February 2020

15
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

General guidelines  Documents all activities related to  Document in the client’s record periodic contacts:
the provision of Health Home o The type of contact: telephone call, secure email
services message, written correspondence, face-to-face visits,
multidisciplinary care team meetings, and attendance
at appointments or other meetings
o Attempted or completed contacts
o Names and relationships of those contacted if not the
client
o Highlights from the conversation
o Objective observations
o Outcome of the contact
o Other important information
o Location of the visit and names and relationship of
collaterals (e.g. family members, guardians, agency
staff, caregivers, or others) present
o Name of staff person completing the activity (include
the writer’s title for the first entry)
Outreach and Engagement  Completes required activities for  Document in the client’s record:
due diligence: o Date and type of letters or program information mailed
o Telephone contacts o Alternate addresses used for clients that are homeless
o Letters o Date letter mailed to the client if a new address is
known or to a collateral who may be able to deliver the
letter to the client
o Date telephone contact initiated and outcome of the
call:
o Date telephone contact attempted and outcome (e.g.,
phone disconnected, wrong number, etc.)

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 1 of 13

16
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

o Note if contact was made with someone other than the
client and the outcome of the call (e.g. left message for
the client)
o Date face-to-face visit scheduled, location, and time.
Include collaterals who will be present and their
relationship to the client
o Due diligence requires three attempts to contact the
client by telephone, document the dates and times of
the calls. Three attempts must be completed during
three different months (do not have to be consecutive
months)
 When telephone contacts and letters do not result in contact
with the client document and date contact with the Lead to
discuss how to proceed with the case
 For this and any other activities document other forms of
communication used to contact the client or collaterals such as
secure email and include the date
Initial contact: client opts  Offers to send the Opt-out Form  Document the client’s record the type of contact (e.g.
out of the program  Completes the Opt-out form if telephone call), the date services were offered, and if known,
client declines to complete the the reason client opted out of the program
form  Document the date the Opt-out Form (HCA 22-853) was mailed
to the client and returned. Or, complete the Opt-out form on
behalf of the client. Note the date the completed form was
submitted to the Lead.
Loss of Contact  Attempts to contact the client by  Document in the client’s record:
mail, secure email, and telephone o Dates and types of contact attempted with client

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 2 of 13

17
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

 Accesses available databases to oDates and types of contact attempted with collaterals,
locate updated contact information their relationship to the client, and the outcome of the
for client contact
 Contacts collaterals and other o Letters mailed to the client including the dates
providers to identify client’s o Contact with the Lead and decision on how to proceed
current location and contact with the case (return case to the Lead or retain and
information attempt to contact in the future)
The Six Core Services:  Initiates contact with client and/or  Document in the client’s record:
Comprehensive Care collaterals o Outreach attempts to locate and contact the client
Management  Completes initial and follow up o Date outreach was completed, who completed the
visits with the client and/or outreach, and names of collaterals if client was not
collaterals contacted
 Completes telephone contacts and o Verbal approval by the client or client’s representative
follow up to contact collaterals and/or share client information
 Reviews PRISM data prior to initial o Date and time of the initial and other face-to-face visits
client contact or face-to-face visit o Other persons present during visits
 Completes the required and o Summary of the purpose of the contact and highlights
optional screenings from the discussion
 Assesses the client’s self- o Notable comments and exchanges
management skills and readiness o Objective observations
 Completes the initial Health Action o Scores, levels, and dates of required and optional
Plan (HAP) OR screenings. Include the name and relationship of the
 Completes a review and updates person if another completes the screening.
the HAP  When the client or representative declines to
 Provides monthly contacts to: complete a required screening note the date,
o Ensure continuity of care reason if given, and the name and relationship
between providers of the person who declined

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 3 of 13

18
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

o Support the client to o Discussion with the client about their activation and
achieve their self-directed readiness to initiate behavioral changes should be
health goals noted
o Assist as needed to o A summary of conversations with the client and
improve functional or collaterals to establish or review the HAP and their
health status or prevent or reported progress on the goals and action steps
slow declines in o Provision of the HAP and the format (e.g. paper copy, a
functioning secure email message, etc.)
 Provides cross-system care o Activities completed or completed by others to support
coordination to identify gaps in the client
care and assist the client in
navigating and accessing needed
services
 Reviews PRISM for updated claims
and utilization activity
 Reviews and revises the HAP if
needed at every contact to:
o Assess completion of
action steps and progress
toward meeting short and
long term goals
The Six Core Services: Care  Ensures communication between  Document in the client’s record:
Coordination the providers o Reviews of the HAP and completion of the required
 Coordinates and acts as a bridge screenings for each four-month activity period
between the client’s system of care o Completion of action steps and any revision to action
including non-clinical support for steps and short term and long term goals in the HAP
 Enter end date and reason if applicable

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 4 of 13

19
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

food, housing, legal services, o If client or collateral declines to participate and note
transportation, and other supports any subsequent attempts to complete screenings
 Facilitates the work of allied staff and/or update the HAP
to assist in care coordination o Closure or transfer of the HAP including an end date
 Provides opportunities for and reason
mentoring and modeling o Names of organizations used to provide social supports
communication with health clearly noting who will make the contact with the
providers such as: provider
o Demonstrating how to o When contact is made describe the interactions,
schedule an appointment conversations, and the plan of action
or leave a message for a o Client’s participation in social/support groups that have
provider increased their knowledge about health care and their
o Participating in joint chronic conditions
medical or other o Interactions with the client, their representatives, allied
appointments staff, and other providers
o Monitoring and offering o Gaps in care or needed services for the client and how
support during telephone these were addressed and the outcome
conversations with health o Activities completed by the Care Coordinator or allied
care and other staff staff such as accompanying the client to an
 Provides interventions that are appointment
tailored to the client’s medical, o Activities that facilitated communication and
social, economic, behavioral coordination between the client, their providers, and
health, cultural, and environmental other support systems to address barriers to achieve
factors impacting the client’s goals
health and health care choices

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 5 of 13

20
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

 Fosters cross-systems
communication between providers
of care including:
o Primary and behavioral
health care providers
o Entities authorizing Long
Term Services and
Supports (LTSS)
 Reviews progress on action steps,
short and long term goals, and
updates or revises the HAP
The Six Core Services: Health  Develops a HAP that is person-  Document in the client’s record:
Promotion centered and promotes recovery o The activation levels, how they may influence the
and resiliency client’s ability to self-manage their chronic conditions,
 Using the client’s activation level and the client’s response to the PAM® and HAP
determines the coaching, teaching, o Discussions with caregivers and parents who complete
and support plan the CAM® or PPAM®
for the client o Visual or audio educational materials given to client or
 Provides person-centered wellness others to promote improved clinical outcomes and
and prevention education to increase self-management skills
include routine and preventative o Use of peer supports to increase the client’s knowledge
care about health conditions and adherence to treatment
 Links the client with resources to o Activities completed by allied staff with the client,
promote a healthier lifestyle such collaterals, and providers, including the date and type
as disease-specific classes and of contact. Documentation may include next steps for
support groups the client, Care Coordinator, and allied staff.

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 6 of 13

21
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

The Six Core Services:  Coordinates with client and/or  Document in the client’s record:
Comprehensive Transitional collaterals to prevent avoidable o Follow up calls and visits before and after discharge
Care readmission after discharge from o Timely follow-up and discussions with inpatient facility
an inpatient facility (hospital, staff, the client, parents, family members, paid and
rehabilitative, psychiatric, skilled unpaid caregivers, providers, collaterals, and others
nursing, substance use disorder involved with the client’s discharge
treatment, or residential o Participation on multidisciplinary care teams,
habilitation setting) outcomes, and plans developed to transition to the
 Ensures that the client and/or community or other setting
collaterals received and o Review of the information sharing consent form/s
understand the discharge plan and noting added or deleted providers with the date
orders o Review of the discharge plan
 Ensures proper and timely follow- o Who received the written discharge plans and if they
up care with a Primary Care are understood
Physician (PCP) and specialists o Scheduled timely appointments with the PCP and/or
 When necessary coordinates other specialists
transportation and escort to o Arrangements for transportation and escort to medical
medical and other appointments and other medical or behavioral health appointments
 Completes or ensures that o Name of person who reconciled medications including
medications have been reconciled the date and relationship to client
 Ensures that red flags have been o Contact with LTSS case manager
identified to the client and/or o Additional support planned for management of high-
collaterals that require contacting risk clients
their medical and behavioral health
providers
 Follows up with LTSS case manager
when there has been a significant
This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 7 of 13

22
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

change with the client’s functional
ability to perform activities of daily
living
 Follows up to ensure that
prescribed treatments and
therapies, medications, supplies,
and durable medical equipment
have been ordered and received
The Six Core Services:  Identifies the role of family  Document in the client’s record:
Individual and Family members, informal supports, and o Names of family members, caregivers, legal
Support paid and unpaid caregivers representatives and other providers and contact
 Provides education and support to information. The Participation Authorization and
family, informal supports, and Information Sharing Consent form, if signed, should
caregivers to: include each of these individuals.
o Increase their knowledge of o Client and family’s engagement with peers and other
chronic conditions formal and informal supports
o Promote the client’s o Client’s participation in peer group or support group
engagement and self- sessions
management o Efforts to facilitate conversations with caregivers about
o Help the client adhere to their chronic conditions and their participation in the HAP
prescribed medications o Discussion about advance care planning and any efforts
 Includes family members, to help the client or family members access legal
caregivers, informal supports, and assistance if an advance directive is requested
other collaterals in the o Use of interpreters for client contact and translation of
development and implementation documents that are culturally and linguistically
of the HAP appropriate for the client

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 8 of 13

23
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

 Works with peer supports, support
groups, and self-management
programs to support the client to
achieve self-management of
chronic condition/s
 Provides information about
advance care planning to clients
and their families within the first
year of engagement
 Facilitates communication and
information sharing with the client,
their families, and other caregivers
 Provides support that considers
language, activation level, health
literacy, and cultural preferences of
the client and family
The Six Core Services:  Identifies community based  Document in the client’s record:
Referral to Community and resources o Referrals to other agencies and providers and actions
Social Support Services  Completes referrals to community taken to actively manage these referrals
and social support services o Support provided to client and collaterals in completing
 Actively manages referrals and submitting applications
 Advocates on behalf of the client to o Support or completion of eligibility reviews for
access medical and behavioral Medicaid, housing, and other services
health care and community and o Resource and referral information including name of
social supports resource, contact name and phone number, and type
of services/supports requested and provided
o Contacts with other service providers
This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 9 of 13

24
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

 Helps acquire and maintain
eligibility for services such as
Medicaid and housing
Health Action Plan (HAP)  Works with the client, family  Document in the client’s record:
members, parents, guardians, o The client’s person-centered long term goal
caregivers, and other collaterals to o The client’s short term goal or goals
establish a person-centered long o Actions steps specifying who will complete the action
term goal, short term goal/s, and step including a due date or general timeframe as
action steps appropriate
 Offers and completes required and o Results of required screenings including the PAM®,
optional screenings and Body Mass CAM®. PPAM®, PHQ-9, PSC-17, Katz ADL, and BMI.
Index (BMI)  If declined note the person who declined,
 In collaboration with the client and reason (if known), and date
collaterals completes required  Note subsequent offers to complete the
fields for the HAP screenings and the outcome
 Enters the HAP into the Lead’s data  Note client’s consent to have the caregiver
platform complete the CAM®
o When optional screenings (My Falls-free Plan, Pain
Scales [FLAAC, Wong-Baker Faces, or Numeric scales],
GAD-7, AUDIT, or DAST) were offered and completed
during each four month activity period or as clinically
indicated
o Initiation and completion of the first HAP and updates
completed during each four month activity period
including:
 Completion or revision of the long term goal,
short term goal/s, and action steps

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 10 of 13

25
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

Obstacles to completing long term goal, short
term goal/s, and/or action steps
o Face-to-face visits for initial and subsequent HAPs and
telephonic support of the client and collaterals in
meeting goals and action steps
Transition Planning  Facilitates discussion with the  Document in the client’s record:
client and/or parents, caregivers, o Discussion of the HAP goals and successes
guardians, or representatives when o Efforts to encourage client to continue to work with
client: allied staff or other collaterals when Health Home
o opts out of the program services are terminated. Document the client’s decision
o is no longer eligible to continue or discontinue their pursuit of goals.
 Acknowledges and celebrates the o Contact with collaterals
client’s successes and provides o Referrals to other providers
coaching to continue efforts to o Client or collateral’s acceptance of an offered service,
improve health such as a referral to a provider. Note if client or
 Develops a plan to ensure collateral decline to accept assistance.
continuity of care after Health o Discussion about the transfer process with the client
Home services end and collaterals and date of discussion
 Educates the client and collaterals o Closure of the HAP including the date and reason.
about the process of health action o Actions taken to transfer the case back to the Lead
planning if the client wishes to
pursue future goals
 Identifies community resources
and completes referrals
 Provides contact information to
client or collaterals for follow-up
for referrals
This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 11 of 13

26
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

 Closes the HAP
Multidisciplinary Care Teams  Organizes a team or participates on  Document in the client’s record:
an existing team o Attempts to develop and execute a cross-system team
o Members of the team and their role including contact
information
o Team meetings including the location and date,
discussion highlights, decisions, and assignments to
team members
Special Programs: Advanced  Educates client and Individual  Document in the client’s record:
Home Care Aide Specialist Provider (IP) about the AHCAS Pilot o Discussions with the client and collaterals about the
(AHCAS) Pilot  May collaborate with client and IP pilot and client’s interest in participating
to develop a role for the IP to o Discussion with the IP about the completion of
support the HAP required training and interest in participating with the
client
o Contact with the Area Agency on Aging or DSHS
Developmental Disabilities Administration case
manager
o Revision of the HAP, with the client’s agreement, to
include a role and possible action steps for the IP to
support the client and their goals.
Special Programs:  Educates the client, collaterals, and  Document in the client’s record:
Community Integration (CI) AFH about the program o Efforts to collaborate with the client, collaterals, and
in Adult Family Homes (AFH)  Identifies resources and AFH provider to assist the client in determining the
opportunities for the client to type of community support they would like to pursue
better integrate into their o Changes to the HAP to incorporate these CI activities as
community goals and action steps

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 12 of 13

27
 Health Home Care Coordination Documentation Guide

Health Home Activities Activities Documentation

 When appropriate, incorporates CI o Contacts with the Developmental Disability
activities into the HAP as goals and Administration Case Resource Manager or DSHS Home
action steps and Community Services Social Service Specialist or
Nurse

This document serves as a guide for documentation of Health Home activities by Care Coordinators and allied staff. Allied staff means Community Health
Workers, peer counselors, wellness or health coaches or other non-clinical personnel who provide supportive services, outreach, and engagement to the
client under the direction and supervision of the Health Home Care Coordinator. Please contact your Lead Organization for additional documentation
requirements. Consult your supervisor for documentation requirements established within your agency.

Rev: January 2018 Page 13 of 13

28
 Guidelines for
HH Staff Roles and Responsibilities February 29, 2016

Health Home Care Coordinators have ultimate responsibility for ensuring the delivery of Health Home services. It is within the scope of their work to delegate
some activities to Allied Staff* and non-clinical administrative support staff. The following graph provides a guide for potential delegation of Health Home
services to Allied and Administrative staff.

CORE ALLIED STAFF

CARE SUPPORT STAFF
HEALTH EXAMPLES OF CORE HEALTH HOME SERVICES, potential roles under
COORDINATOR under the direction of
HOME INTERVENTIONS and ACTIVITIES direction of the Care
the Care Coordinator
functions
SERVICES Coordinator
Outreach and Contact the client to introduce Health Home benefits and schedule initial √ √ √
Engagement Care Coordinator face-to-face visit.

Comprehensive Conduct comprehensive health assessment/reassessment inclusive of √

Care Services medical/behavioral /rehabilitative and long term care and social service need.

Complete or revise Health Action Plan (HAP), with a face to face visit with √
the client to identify client's goals and action steps. Development of the HAP
may include family members, caregivers, and other social supports as
appropriate.
Consult with interdisciplinary care team on client’s care plan/needs/goals. √
Consult with primary care physician and/or any specialists involved in the √
treatment plan.
Conduct client outreach and engagement activities to assess on-going √ √
emerging needs and to promote continuity of care and improved health
outcomes.
Prepare client crisis intervention or resiliency plan. √
Care Coordinate with service providers and health plans as appropriate to secure √
Coordination necessary care and share crisis intervention (provider) and emergency
information.
Communicate with service providers and health plans as appropriate to √ √
secure necessary care and supports.
Link/refer client to needed services to support care plan/treatment goals, √ √
including medical/ behavioral health care; patient education, and self-
help/recovery, medication adherence, health literacy, and self-management.
1

29
 Guidelines for
HH Staff Roles and Responsibilities February 29, 2016
CORE ALLIED STAFF
CARE SUPPORT STAFF
HEALTH EXAMPLES OF CORE HEALTH HOME SERVICES, potential roles under
COORDINATOR under the direction of
HOME INTERVENTIONS and ACTIVITIES direction of the Care
the Care Coordinator
functions
SERVICES Coordinator
Conduct case reviews with interdisciplinary care team to monitor/evaluate √
client status and service needs.
Advocate for services and assist with scheduling of needed services. √ √
Coordinate with treating clinicians to assure that services are provided and to √
assure changes in treatment or medical conditions are addressed.
Assist and support client with scheduling medical and applicable √ √
appointments.
Accompany the client to medical and other applicable appointments. √
Develop a crisis intervention or resiliency plan and revise care plan/goals as √
required.
Health Provide customized educational materials according to the needs and goals of √ √
Promotion the client, caregiver, or other social supports as appropriate.
√ √
Promote participation in community educational and support groups.

√ √
Provide links to health care resources that support the client’s goals.

Develop and execute cross-system care coordination activities to assist the √

client in accessing and navigating needed services.

Support the execution of cross-system care coordination activities that assist √ √

clients in accessing and navigating needed services.

√ √ √
Distribute health education and other materials.

Assist with follow up calls and provide appointment reminders. √ √ √

Comprehensive Follow up with hospitals/ER upon notification of a client's admission and/or √
Transitional discharge to/from an ER, hospital or rehabilitative setting.
Care
Facilitate discharge planning from an ER, hospital, or rehabilitative setting to √

30
 Guidelines for
HH Staff Roles and Responsibilities February 29, 2016
CORE ALLIED STAFF
CARE SUPPORT STAFF
HEALTH EXAMPLES OF CORE HEALTH HOME SERVICES, potential roles under
COORDINATOR under the direction of
HOME INTERVENTIONS and ACTIVITIES direction of the Care
the Care Coordinator
functions
SERVICES Coordinator
ensure a safe transition/discharge that ensures care needs are in place.
Notify/consult with treating clinicians, schedule follow up appointments, and √
assist with medication reconciliation.
Follow-up post discharge with client/family to ensure client understands √
discharge orders and medication reconciliation has been completed.
Support client with connecting to community supports to ensure that needed √ √ √
services or equipment are received.
Individual & Develop, review, or revise the client’s Health Action Plan with the client, √
Family Support family, or caregiver to ensure that the plan reflects client’s preferences, goals,
education, and health literacy to support health self-management.
Educate client, family, or caregiver on advance directives, client rights, and √ √
health care issues, as needed.
Meet with client and family, inviting any other providers to facilitate needed √ √
interpretation services.
Refer client/family to peer supports, support groups, social services, √ √
entitlement programs as needed.
Referral to Identify, refer and facilitate access to relevant community and social support √ √
Community & services that support the client’s health action goals.
Social Support
Services
Assist client to apply for or maintain eligibility for health care services, √ √
disability benefits, housing, and legal services not provided through other
case management systems.
Provide general information about upcoming community events. √ √ √

* Allied health care staff, as identified in the Washington State Plan Amendment, means community health workers, peer counselors or other non-clinical personnel who
provide supportive services to the client under the direction and supervision of the Health Home Care Coordinator.

31
 Health Home Participation Authorization Information Sharing Consent Form Guidance

Health Home Consent Guidance How to complete the form

Purpose • To create a streamline process for • To be considered a valid consent the following must be
completing the Health Home completed. Pages 1 & 2 must be part of the beneficiary record.
participation authorization and
information sharing consent.
Page 1 – Health Home • Complete the Health Home Participation Authorization
Participation Authorization Information Sharing Consent form.
• Make sure to include both pages in client record.
• Print name of beneficiary • Beneficiary name must be printed clearly.
• Print name of Health Home lead • Health Home lead name must be printed clearly.
• Signature of beneficiary or • There must be a signature on this line.
beneficiary’s legal representative
• Date • The full date must be clearly written.
Providing verbal consent • When it is not possible to get the • Document in the beneficiaries file if they provided verbal
beneficiary’s signature prior to consent or not.
services, the Care Coordinator (CC) • Document name of person giving consent, the date consent
may explain or read the Health was given and if there were any witnesses. Also document how
Home Participation Authorization the CC will follow up. For Example:
form. The CC must clearly ▪ Mailing a copy of the form with a return envelope
document the interaction for the beneficiary to sign, or
▪ Mailing a copy to the beneficiary.

Note: Make sure to document on the form itself and in the notes.
Adolescent Beneficiary • If the beneficiary is between the • Complete the Health Home Adolescent Information Sharing
ages of 13-17 you must fill out the Consent form.
Health Home Adolescent Note: The Adolescent Information Sharing Consent form may
Information Sharing Consent form not be provided verbally.
(this is in addition to the Health
Home Participation form)

This document serves as a guide for documentation of Health Home Participation Authorization Information Sharing Consent. Please contact the Lead Organization for additional
documentation requirements. Consult supervisor for documentation requirements established within the agency.

December 2022

32
 Health Home Participation Authorization Information Sharing Consent Form Guidance

Information Sharing Consent

Portion of Document
Optional disclosure for • For the consent to be valid when • Initials must be next to the mental health field and/or the
mental health, HIV/AIDS and the beneficiary health records HIV/AIDS and STD results, diagnosis, or treatment field.
STD results, diagnosis, or include any mental health,
treatment HIV/AIDS or STD information, this Note: A check mark or a line across the box is NOT considered a
section must also be complete. valid consent.
SUD – To give consent for • Beneficiary must complete a • Complete the Release of information (ROI) for substance use
the release of confidential separate release of information for disorder (SUD) services and attach in file.
alcohol or drug treatment substance use disorder (SUD) form
Note: The release of information for substance use disorder (SUD)
form may not be provided verbally.

Validity of the consent form • Beneficiary must initial option for • Either initial “this consent is valid as long as the Health Home
consent to be valid needs my records of the program” or initial “until” and print a
clear date.

Note: A check mark or line across the box is NOT considered a

valid consent.
Print name of beneficiary • Print the full name of the • Beneficiary name must be visible and printed or typed in the
beneficiary document.
Beneficiary’s date of birth • Print the beneficiary’s full date of • Print the beneficiary’s full date of birth. Example: 01/01/2020
birth or January 01, 2020
Signature of beneficiary or • Must be signed for the consent to • Beneficiary or beneficiary’s legal representative signs the
beneficiary’s legal be valid (See Providing verbal information sharing consent portion of the form.
representative consent, below)
Providing verbal consent for • When it is not possible to get the • Document in the beneficiaries file if they provided verbal
beneficiary or beneficiary’s beneficiary’s signature prior to consent or not.
legal representative services, the Care Coordinator (CC) • Document name of person giving consent and date/time if
may explain or read the Health there were witnesses and how the CC will follow up. For
Home Participation Authorization example, mailed the form with a return envelope for the
beneficiary to sign, or mailed a copy to the beneficiary.
This document serves as a guide for documentation of Health Home Participation Authorization Information Sharing Consent. Please contact the Lead Organization for additional
documentation requirements. Consult supervisor for documentation requirements established within the agency.

December 2022

33
 Health Home Participation Authorization Information Sharing Consent Form Guidance

form. The CC must clearly Note: Make sure to document on the form itself and in the
document the interaction notes.
Date • Full date must be visible and clearly • Print the date the beneficiary signed the consent. Example:
written 01/01/2020 or January 01, 2020.
Print name of legal • Print the full name of the legal • Legal representative name must be printed clearly.
representative (if applicable) representative if applicable
Relationship of legal • Print the relationship of legal • Print the relationship of legal representative to beneficiary if
representative to representative to beneficiary if applicable.
beneficiary applicable
Page 2 – Release of
information
If there is a past lead or CCO • Past lead or CCO will not be able to • Print the name of the past lead or CCO and have beneficiary
make sure to clearly write in share information if this is section date and initial. Note: If there is not a full date or initials of the
their name is not complete beneficiary the release of information is NOT considered valid.
List any and all • Each entity, providers or people • Clearly print the name of the provider/facility/people.
providers/people/facilities must have their own line item to • Note: If there is not a full date or initials of the beneficiary, the
in the following lines that be considered a valid release. release of information is NOT considered valid.
the beneficiary would like to • If the consent is prepopulated with
have the CC be able to share provider types, example; Provider,
health information with PCP, Pharmacy – the CC should
prompt the beneficiary to provide
a specific provider and add their
name in the form

Annual Consent Review

Review date • Each year, the CC should be reviewing document with
• (MM/DD/YYYY): Full date must be beneficiary.
visible and clearly written
• Print the date the beneficiary signed the consent. Example:
01/01/2020 or January 01, 2020.
• Care Coordinator Name • Care Coordinator will print their name and sign each time they
review document with beneficiary.
This document serves as a guide for documentation of Health Home Participation Authorization Information Sharing Consent. Please contact the Lead Organization for additional
documentation requirements. Consult supervisor for documentation requirements established within the agency.

December 2022

34
 Health Home Participation Authorization Information Sharing Consent Form Guidance

• Care Coordinator Signature • Care Coordinator will print their name and sign each time they
review document with beneficiary.

Providing a copy of the • Provide a copy of the Health Home • Document if a copy was provided to the beneficiary.
Health Home Participation Information Sharing Consent Form
and information Sharing upon request.
Consent Form
Examples of a valid release Name of provider/partner Date Beneficiary initials
of information • Providence Health System 01/01/2020 AA
• Jane Smith 01/01/2020 AA
Dr. Jimmy Waters 01/01/2020 AA
Examples of NOT a valid Do not write in generic provider • Any Provider
release of information categories such as ‘dental care • Any hospital
provider’ or ‘primary care doctor.’ • No name at all
A specific provider name and/or • “Whoever needs information”
specific treating clinic should be Acronyms for health care providers such as “CHI” or “MHS”
identified by the beneficiary
Beneficiary withdrawing The beneficiary may withdrawal • The beneficiary will sign and date the form if they are available
participation in the Health the Participation Authorization for to do so.
Home program Health Home at any time they • If the beneficiary declines, the care coordinator will complete
chose. If available, the client will on the beneficiary’s behalf and mail a copy to the beneficiary.
sign Health Home Participation
(Opt-Out/Decline Services.
Beneficiary adding or If the beneficiary chooses to add or • The beneficiary must also initial and date the consent for the
withdrawing consent for withdrawal consent for providers, addition or withdrawal to be considered valid.
specific providers/partners they may do so by filling out the
consent form. For adding a
provider/partner use the
“beneficiary gives consent” section
of the form. If the beneficiary
would like to withdrawal consent,
they must fill out the “beneficiary
This document serves as a guide for documentation of Health Home Participation Authorization Information Sharing Consent. Please contact the Lead Organization for additional
documentation requirements. Consult supervisor for documentation requirements established within the agency.

December 2022

35
 Health Home Participation Authorization Information Sharing Consent Form Guidance

withdrawals consent” columns on

the consent form
Beneficiary information • Explain to the beneficiary on how • Provide information that providers/partners will use the
sharing consent process their information and sharing beneficiary’s health information to coordinate and help the
process will be used. beneficiary’s health care.
• Please see page 3 of the consent form for details regarding
beneficiary information sharing consent process.
Notes • A line down the page after first initial or first date is NOT
considered valid.
• A check mark instead of initials is NOT considered valid.
• If there is not a full date the release is NOT considered valid
example 12/21 (unclear if this is December 2020 or December
21, Year?), 12/20 (unclear if this is December 20th or December
2020).
• Date must be filled out as follows:
o 01/01/2020
o January 1, 2020
o 01/01/20
• Beneficiary initials MUST be on each line that has an entity
attached.
• The Health Home Participation Authorization must be filled out
by the beneficiary to begin Health Home services, but the
Information Sharing Consent form is optional. Note, if the
Information Sharing Consent form is not filled out the CC may
not share information with any of the providers etc.

This document serves as a guide for documentation of Health Home Participation Authorization Information Sharing Consent. Please contact the Lead Organization for additional
documentation requirements. Consult supervisor for documentation requirements established within the agency.

December 2022

36
37
PRISM Health Report for JOHN DOE
Print Date: 2018-08-31

Date of Birth: 1989-12-09

Age: 28 years 8 months 22 days

Gender: Male

ProviderOne ID: 100000000WA

View or print as PDF

Last Well-Child exam/EPSDT

No record found.

Last dental appointment

No record found.

Health conditions
Recent diagnosis(ICD-9 Code) Last Date Provider Provider Phone
FLAIL CHEST (8074) 2018-06-26
TRACHEOSTOMY STATUS (V440) 2018-06-05
PULMONARY COLLAPSE (5180) 2018-06-04
PLEURAL EFFUSION NOS (5119) 2018-06-04
MILD COGNITIVE IMPAIRMENT (33183) 2018-05-26
ALCOHOL ABUSE-UNSPEC (30500) 2018-05-26
MANDIBLE FX NOS-OPEN (80230) 2018-05-26
HYPOPOTASSEMIA (2768) 2018-05-15

Hospital stays
Admission Service Primary Length Provider
ER Provider
Date End Date Diagnosis(ICD-9 Code) of Stay Phone
REHABILITATION (xxx) xxx-
2018-05-26 2018-06-01 No 6 days Hope Hospital
PROC NEC (V5789) xxxx
QUALITY HEALTH (xxx) xxx-
2018-06-26 2018-07-17 FLAIL CHEST (8074) No 21 days
CARE SYSTEM xxxx

January 2018

38
Emergency room visits
Primary
Provider
Visit Date Diagnosis Alcohol Drug Injury Psych Other Provider
Phone
(ICD-9 Code)
OPEN
2018-02- WOUND OF Healthy Options (xxx) xxx-
yes
26 FOREARM Blind/Disabled xxxx
(88100)
OPEN
2018-02- WOUND OF Healthy Options (xxx) xxx-
yes
28 FOREARM Blind/Disabled xxxx
(88100)
PULMONAR UNITED STATES
2018-06- (xxx) xxx-
Y COLLAPSE yes HEALTH
04 xxxx
(5180) CONFERENCE

Professional Office and non-ER Hospital Outpatient Visits in

last 180 days
May include ancillary professional claims associated with an outpatient ER visit
Primary Diagnosis Provider
Visit Date Procedure Servicing Provider
(ICD-9 Code) Phone
OPEN WOUND
(xxx) xxx-
2018-03-25 OF FOREARM Emergency dept. visit Healthy Options Blind/Disabled
xxxx
(88100)
OPEN WOUND
Repair superficial (xxx) xxx-
2018-03-19 OF FOREARM Healthy Options Blind/Disabled
wound(s) xxxx
(88100)
OPEN WOUND
2018-03-19 OF FOREARM Emergency dept. visit BOWER, MARK
(88100)
OPEN WOUND
(xxx) xxx-
2018-02-19 OF FOREARM Emergency dept. visit Healthy Options Blind/Disabled
xxxx
(88100)
OPEN WOUND
Repair superficial
2018-02-19 OF FOREARM BOWER, MARK
wound(s)
(88100)

Prescriptions filled in last 90 days

No record found.

Prescriptions by drug classes in last two years

Pharmacy
Fill Date Generic Name Drug Class Prescriber Pharmacy
Phone
IBUPROFEN TAB JACOB WAL-MART (xxx) xxx-
2018-06-26
800 MG BYRON MD PHARMACY xxxx

January 2018

39
 HYDROCODONE-
THOMAS
ACETAMINOPHE ANALGESICS,NAR WAL-MART (xxx) xxx-
2018-06-16 JEFFERSON
N TAB 7.5-325 COTICS PHARMACU xxxx
MD
MG
SENNOSIDES
LAXATIVES AND (xxx) xxx-
2018-06-01 SYRUP 8.8 Scott, Darrin Hope Hospital
CATHARTICS xxxx
MG/5ML
RANITIDINE HCL ANTI-ULCER (xxx) xxx-
2018-06-01 Scott, Darrin Hope Hospital
TAB 150 MG PREPARATIONS xxxx
IPRATROPIUM-
ALBUTEROL
(xxx) xxx-
2018-06-01 AEROSOL 18-103 Scott, Darrin Hope Hospital
xxxx
MCG/ACT (20-
120MCG/ACT)
AMOXICILLIN &
K (xxx) xxx-
2018-06-01 PENICILLINS Scott, Darrin Hope Hospital
CLAVULANATE xxxx
TAB 875-125 MG

Disclaimer
The enclosed healthcare information is confidential and is to be used solely for meeting the medical needs of this patient. It may only be
shared with the patient’s healthcare provider(s). Redisclosure of this information can only be made with the patient's written consent or
other appropriate legal authorization. This information is also protected under federal and state law. It is provided to you for the limited
purposes of meeting the needs and ensuring the safety and well-being of patient placed in your care. You may discuss the information
with the patient or the patient’s healthcare providers.

January 2018

40
1 Client Vignettes Health Home Training Manual

Sacha

High-risk elder receiving in-home personal care

1. Demographics
a. 69 year-old woman
2. Coverage status including plan enrollment
a. Dually eligible for Medicaid and Medicare
3. Current living arrangements
a. Living at home and authorized for about 4 hours per day of Community First Choice
Program personal care
4. Major medical risk factors
a. Chronic heart disease
b. Chronic kidney disease
c. Diabetes Type II, poorly controlled
d. Rheumatoid arthritis
e. Pulmonary collapse
f. Chronic pain
5. Behavioral health risk factors
a. Depression
6. IP use and primary diagnosis
a. Hospitalized 4 times in past year
b. Twice related to UTI
c. Once for chest pain
d. Most recently with diabetic coma
7. ED use and primary diagnoses
a. 30 visits in past year
b. Common primary diagnoses include
i. Diabetes
ii. UTI
iii. Chest pain and other pain
iv. Dizziness
v. Headache
vi. Injuries from falls
8. CARE assessment information
a. Moderate ADL needs
b. High depression score
c. Mild-moderate cognitive impairment
d. Current behaviors
i. Easily irritated
ii. Hallucinations
1
January 2018

41
2 Client Vignettes Health Home Training Manual

iii. Obsessed with her disease and limited abilities

e. Fall risk – recently fell in bathroom
f. Chronic pain limits activity
g. Multiple functional limitations
9. Primary care provider
a. Frequently visits local community health clinic, with encounters with multiple servicing
providers associated with evaluation and management procedure codes

2
January 2018

42
3 Client Vignettes Health Home Training Manual

Carmella

High-risk disabled adult with serious mental illness

1. Demographics
a. 25 year old woman
2. Coverage status including plan enrollment
a. SSI-related Medicaid, recently enrolled with a health plan but dropped back to Fee-For-
Service
3. Current living arrangements
a. Living at home
4. Major medical risk factors
a. Diabetes
b. Epilepsy
c. Asthma
d. Septicemia
e. Hypertension
f. Gastric acid disorder
5. Behavioral health risk factors
a. Schizophrenia
b. Bipolar
c. PTSD
d. Borderline personality
e. Depression
f. No co-occurring substance abuse identified
6. IP use and primary diagnoses
a. Hospitalized 8 times in past 15 months
b. Most recently for apparent suicide attempt led to medical hospitalization for analgesic
overdose, followed by an E&T admission for mental health, followed by transfer to
community psychiatric hospital
c. Prior admissions for:
i. Depression (psych E&T)
ii. Gastritis
iii. Septicemia
iv. Epilepsy
v. Muscle pain

3
January 2018

43
4 Client Vignettes Health Home Training Manual

7. ED use and primary diagnoses

a. 49 visits in past 15 months
b. Common primary diagnoses include
i. Depression, anxiety, bipolar
ii. Convulsions
iii. Adult sexual abuse
iv. Analgesic overdose
v. Diabetes
vi. Asthma
vii. Contusions
viii. Injuries
ix. Pain
8. CARE assessment information
a. N/A
9. BHO services
a. Frequent therapy visits and crisis intervention services
10. Primary care provider
a. Little evidence of primary medical provider relationship

4
January 2018

44
5 Client Vignettes Health Home Training Manual

Tom

High medical risk disabled with serious mental illness and co-occurring substance use disorder

1. Demographics
a. 54 year old man
2. Coverage status including plan enrollment
a. SSI-related Medicaid
3. Current living arrangements
a. Currently homeless following release from jail 12 months ago.
4. Major medical risk factors
a. Renal – cystostomy, catheter, frequent UTI
b. Spinal cord injury, Hemiplegia/hemiparesis
c. Arthritis
d. Cardiovascular – complications/auto cardiac defibrillator
e. Diabetes
f. Cataracts
g. Pneumonia
5. Behavioral health risk factors
a. Schizophrenia
b. Co-occurring alcohol abuse
6. IP use and primary diagnosis
a. Hospitalized once in past 15 months for UTI
7. ED use and primary diagnosis
a. 78 visits in past 15 months primarily to treat problems with urinary catheter and chronic
UTI
8. CARE assessment information
a. Applied for personal care but never received assistance
9. BHO services
a. Currently receiving BHO-funded services, 2-3 OP visits per month
10. Primary care provider
a. Does not appear to have established medical PCP

5
January 2018

45
6 Client Vignettes Health Home Training Manual

Luchita

High medical risk child with developmental delay and behavioral factors

1. Demographics
a. 6 year old girl
2. Coverage status including plan enrollment
a. SSI-related Medicaid
3. Current living arrangements
a. Began living at home with her mother in the past three months, prior to that she was in
foster care for over one year
4. Major medical risk factors
a. Gastrostomy
b. Immune system disorder
c. Spontaneous ecchymosis (bruising)
d. Heart disease
e. Conduct disorder not otherwise specified
f. Failure to thrive
5. Behavioral health risk factors
a. Conduct disorder not otherwise specified
b. Developmental delay
c. PSC-17 score: 12 (scored 7 points on the attention scale)
6. IP use
a. Hospitalized 3 times in past 15 months (general medical)
7. ED use and diagnosis
a. One ED visit in past 15 months for vomiting
8. No CARE assessment information is available, no nursing facility admissions
9. Receives speech therapy on a weekly basis for hearing and language development
10. Primary care provider
a. Appears to have an established relationship with a PCP and her cardiologist

6
January 2018

46
7 Client Vignettes Health Home Training Manual

Jacob

High-risk developmental delay

1. Demographics
a. 21 year old man
2. Coverage status including plan enrollment
a. SSI-related Medicaid
3. Current living arrangements
a. Living at home with parents for past three months after being evicted from an adult
family home
4. Major medical risk factors
a. Splenomegaly
b. Cardiac dysrhythmias
c. Asthma
d. Fractures
e. Esophageal reflux
f. Pain medication use
5. Behavioral health risk factors
a. Mild intellectual disability
b. Oppositional disorder
c. Psychosis
d. Prescribed antipsychotics, antidepressants, and narcotics
6. IP use
a. Not hospitalized in past 15 months
7. ED use and primary diagnoses
a. 54 visits in past 15 months
b. Common primary diagnoses include
i. Concussions, contusions, open wounds, and other injuries
8. CARE assessment information
a. Moderate cognitive impairment
b. Problem behaviors
i. Paranoia
ii. Mood swings
iii. Verbally abusive
9. BHO services
a. Ongoing (at least monthly) community mental health center visits
10. Primary care provider
a. No indication of stable PCP relationship

7
January 2018

47
 Health Home Training

PRISM SCREENS
The following images display the types of information available in the current version of
PRISM. Please note that these examples are for fictitious clients.

Events

48
 Health Home Training

Drug Adherence

49
 Health Home Training

Eligibility
and Demographics

50
 Health Home Training

Risk Factors

A Risk Score estimates the client’s expected future medical costs given their risk factors: gender, age, diagnoses and medications. The
information is based on fee-for-service and managed care encounter claims data from the past 15 months (24 months for children).

Interpretation: If a client has a risk score of 1.5 that means that their expected medical expenditures in the next year are expected to be
50% greater than the average Medicaid client in the SSI blind/disabled category.

The risk score is only a starting point – Don’t take the numeric value too literally. A client with a score of 1.20 will generally be less complex
than a client with a score of 7.0, but the differences between 1.2 and 1.3 are likely to be negligible from a care management perspective.
The score can vary somewhat every week, based on changes in age or new claims being processed. However, once a Medicaid client is
identified as “clinically qualified”, they stay qualified regardless of their PRISM score.

A risk score can be broken down into risk factors. Risk factors include diagnoses grouped together based on disease category. The
diagnosis groups are further broken down by the degree of increased expenditures associated with that group, such as “high cost, medium
cost, low cost”. The risk factors are provided to assist you in identifying the multitude needs of the client.

51
 Health Home Training

IP Score

52
 Health Home Training

Claims
Claims and Encounters

53
 Health Home Training

Outpatient
Professional Office, Ambulatory Surgery Center and non-ER Hospital Outpatient Visits

54
 Health Home Training

IP
Inpatient

55
 Health Home Training

RX
Prescriptions filled

56
 Health Home Training

Emergency Room
Emergency Room Visits that did not result in an inpatient admission

Four columns indicate the probability that the Emergency Room visit is:
NE - Non Emergent. The patient’s initial complaint, symptoms, vitals, history and age indicated that medical care was not
required within the next 12 hours;
EPCT - Emergent: Primary Care Treatable. Treatment was required within 12 hours and could have been provided outside of
the ER;
EPCP - Emergent: Emergency Room Care Needed, Illness Preventable. The health episode could have been avoided with
timely primary care treatment; and/or
ENP - Emergent: Emergency Room Care Needed, Not Preventable health episode could not have been avoided.

Interpretation: The first ER visit here, Chest Pain NOS has a 32% probability of being Emergent, Primary Care Treatable and a
68% probability of being Emergent, Emergency Room Care Needed, Not Preventable based on a study conducted by New
York University (http://wagner.nyu.edu//chpsr/index.html?p=62).

Five (5) types of ER visits do not have a prevention probability assigned to them; they are just assigned a group based on the
diagnosis code: Alcohol, Drug (excluding alcohol), Injury, Psych or Other.

These categories can help you quickly scan the list to determine which visits may have been avoidable or determine patterns
of ER visits.

10

57
 Health Home Training

Alcohol or Drug

Mental Health
11

58
 Health Home Training

Long Term Care

12

59
 Health Home Training

NOTE: Long Term Services and Supports (LTSS) may also be located under the Claims screen.

13

60
 Health Home Training

Labs

14

61
 Health Home Training

Providers

15

62
 Health Home Training

CARE
Long Term Care functional assessments

16

63
 Health Home Training

PAM
Patient Activation Measures

17

64
 Health Home Training

HRI
Health Risk Indicators for children only

18

65
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
REASON FOR CLOSURE OF THE HAP REASON FOR TRANSFER OF THE HAP
Beneficiary Opted Out Move to a county that does not have Health Home services Client choice to change CCO or Lead Organization
Death No longer eligible Eligibility changed (change to/from FFS or MCO)
CLIENT INTRODUCTION
Jordan is a 59 year-old woman who has lived a very active life: bicyling, running, and exploring. She wants to overcome her arthritis problems and become active again.
CLIENT’S LONG TERM GOAL DIAGNOSIS (PERTINENT TO HAP)
Jordan wants to go camping on the Olympic Penninsula in the summer of 2019. Osteoarthritis in knees and spine. History of bursitis in right shoulder.
Initial / Annual HAP Required Screenings Four Month Update Required Screenings Eight Month Update Required Screenings
IF NOT COMPLETE,
SCREEN DATE SCORE / LEVEL IF NOT COMPLETE, EXPLAIN SCREEN DATE SCORE / LEVEL SCREEN DATE SCORE / LEVEL IF NOT COMPLETE, EXPLAIN
EXPLAIN
PAM 07/20/2018 86.3 / 4 PAM 11/30/2018 77.5 / 4 PAM 04/25/2019 82.8 / 4
CAM / CAM / CAM /
PPAM / PPAM / PPAM /
Katz ADL 07/20/2018 4 Katz ADL 11/30/2018 5 Katz ADL 04/25/2019 5
PHQ-9 07/20/2018 3 PHQ-9 11/30/2018 3 PHQ-9 04/25/2019 2
PSC-17 PSC-17 PSC-17

BMI 07/20/2018 31 BMI 11/30/2018 30 BMI 04/25/2019 29

OPTIONAL SCREENING SCORES OPTIONAL SCREENING SCORES OPTIONAL SCREENING SCORES
SCREEN DATE SCORE SCREEN DATE SCORE SCREEN DATE SCORE

DAST DAST DAST

GAD-7 GAD-7 GAD-7

AUDIT AUDIT AUDIT

FALLS FALLS FALLS
RISK
07/20/2018 5 RISK
11/30/2018 4 RISK
04/25/2019 4
FLACC FACES
PAIN 07/20/2018 7 FLACC FACES NUMERIC PAIN 11/30/2018 6 NUMERIC
PAIN 04/25/2019 5 FLACC FACES NUMERIC
ADDITIONAL COMMENTS ADDITIONAL COMMENTS ADDITIONAL COMMENTS
Met for first HAP and goal setting. Jordan reports a Jordan worked hard in partnership with her personal Jordan relates that her pain has decreased. She is able to be
moderate level of pain due to arthritis. She reports she is trainer at the Y. She is beginning to see some progress, more active for longer periods of time. She has established a
afraid of failure due to her painful joints but is ready to especially with weight loss, stamina, pain, and home exercise program and a program at the Y designed by
work on achieving her long term goal. independence with ADLs; she can now transfer by herself. her trainer. She is planning a brief camping trip in June.
DSHS 10-481 (REV. 02/2015) PAGE 1
66
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Increase walking distance in neighborhood Short Term Goal: Join the YWCA and get a personal trainer Short Term Goal: Gain better control of arthritis and pain
Goal Start Date: 07/20/2018 Goal End Date: 11/19/2018 Goal Start Date: 11/20/2018 Goal End Date: 03/19/2019 Goal Start Date: 03/20/2019 Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE
07/20/2018 11/19/2018 07/23/2018: 11/20/2018 03/19/2019 11/20/2018: 03/20/2019 03/20/2019:
1. Jordan will walk a half of a 1. Martha will contact the 1. Jordan will make an
block daily YWCA to see if Jordan can get appointment with her
07/30/2018: a free or reduced rate for rheumatologist and a pain
2. Jordan will add stretching Jordan's membership. She may specialist.
before and after walking contact other agencies, such as 03/29/2019:
08/06/2018: the Area Agency on Aging, for 2. Martha will contact Jordan
3. Martha will call Jordan to other suggestions for to see if she needs assistance
ask about her progress and subsidizing Jordan's preparing for her visits. She
remind her of her next action membership. She will call will encourage and assist her as
step. Jordan to inform her of the needed to write down her
08/13/2018: results of her inquiries. medications and questions for
4. Jordan will increase walking 11/26/2018: both specialist appointments.
to 1 block a day. 2. Jordan will contact the Y to She will get the dates for the
09/17/2018: apply for a membership. She appointments and ensure that
5. Jordan will increase walking will also ask about a personal Jordan has transportation and
trainer and schedule an an escort (possibly her paid
to 2 blocks a day.
appointment for an assessment caregiver) for both
10/15/2018:
and exercise plan. appointments.
6. Martha will contact Jordan
12/10/2018:
to see if she wants to increase
3. Martha will follow up with
her walking distance to 3 blocks
Jordan to see if she got her
per day.
membership and set up an

DSHS 10-481 (REV. 02/2015) PAGE 2

67
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Increase walking distance to 1 block a day Short Term Goal: Join the YWCA and get a personal trainer Short Term Goal: Gain better control of arthritis and pain
Goal Start Date: 07/20/2018 Goal End Date: 11/22/2018 Goal Start Date: 11/20/2018 Goal End Date: 03/19/2019 Goal Start Date: 03/20/2019 Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE
11/20/2018 03/19/2019 appointment with the trainer. 03/20/2019 04/25/2019:
12/17/2018: 3. Martha will visit Jordan to
4. Jordan will meet with the find out how her appointments
trainer and begin her went with the two specialists.
prescribed exercise program. They will review the HAP to see
She will continue her walking if any revisions are needed to
and stretching program as her existing goal or if a new
weather permits at home or at goal is needed based on what
the Y. her doctors precribe. Jordan
01/03/2019: will complete the required
Melody will provide an exercise screenings and the pain and
and walking tracker for Jordan falls assessment to see if there
to complete during their has been any improvement.
January visit and they will
review it at each monthly visit.

DSHS 10-481 (REV. 02/2015) PAGE 3

68
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

DSHS 10-481 (REV. 02/2015) PAGE 4

69
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

DSHS 10-481 (REV. 02/2015) PAGE 5

70
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

DSHS 10-481 (REV. 02/2015) PAGE 6

71
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Jordan Larson 05/30/1959 111111111WA
(HAP) HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
Statewide Lead 206 111-5554
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
07/20/2018 07/20/2018 Best CCO Martha Stewart 306 555-1111
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

DSHS 10-481 (REV. 02/2015) PAGE 7

72
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
REASON FOR CLOSURE OF THE HAP REASON FOR TRANSFER OF THE HAP
Beneficiary Opted Out Move to a county that does not have Health Home services Client choice to change CCO or Lead Organization
Death No longer eligible Eligibility changed (change to/from FFS or MCO)
CLIENT INTRODUCTION
Bobby is 48 years old and lives in his own apartment. He hears voices and sometimes yells at them when he is scared. Neighbors have complained to the landlord about his loud voice.
.
CLIENT’S LONG TERM GOAL DIAGNOSIS (PERTINENT TO HAP)
Bobby wants to be able to breath better when he gets scared. Schizophrenia and Chronic Obstructive Pulmonary Disease (COPD)
Initial / Annual HAP Required Screenings Four Month Update Required Screenings Eight Month Update Required Screenings
IF NOT COMPLETE,
SCREEN DATE SCORE / LEVEL IF NOT COMPLETE, EXPLAIN SCREEN DATE SCORE / LEVEL SCREEN DATE SCORE / LEVEL IF NOT COMPLETE, EXPLAIN
EXPLAIN
PAM 08/15/2017 32.2 / 1 PAM / PAM /
CAM / CAM / CAM /
PPAM / PPAM / PPAM /
Katz ADL 08/15/2017 6 Katz ADL Katz ADL

PHQ-9 08/15/2017 12 PHQ-9 PHQ-9

PSC-17 PSC-17 PSC-17

BMI 08/15/2017 26 BMI BMI

OPTIONAL SCREENING SCORES OPTIONAL SCREENING SCORES OPTIONAL SCREENING SCORES

SCREEN DATE SCORE SCREEN DATE SCORE SCREEN DATE SCORE

DAST DAST DAST

GAD-7 08/15/2017 14 GAD-7 GAD-7

AUDIT AUDIT AUDIT

FALLS FALLS FALLS
RISK RISK RISK
FLACC FACES
PAIN FLACC FACES NUMERIC PAIN PAIN FLACC FACES NUMERIC
NUMERIC
ADDITIONAL COMMENTS ADDITIONAL COMMENTS ADDITIONAL COMMENTS
Bobby's PHQ-9 and GAD-7 scores indicate a need for a
mental health assessment. A Peer Support Program is
recommended. He reports that his biggest concern is going
to see a doctor so he can "get his breathing checked".
DSHS 10-481 (REV. 02/2015) PAGE 1
73
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Get a doctor (primary care physician). Short Term Goal: Short Term Goal:
Goal Start Date: 08/15/2017 Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE
08/15/2017 08/21/17:
1.Melody will refer Bobby to a
Mental Health Peer Support
Program and will provide the
Peer Support Specialist with
the names of three doctors
offices near Bobby's home.
09/05/17:
2.The Peer Support Specialist
will meet Bobby and drive him
by the three doctors offices.
Bobby will choose the clinic he
likes the best.
09/11/17:
3. Melody will call Bobby and
ask him to select a doctor from
the clinic he chooses.
09/13/17:
4. Melody will schedule an
appointment with a doctor at
the clinic of Bobby's choice.

DSHS 10-481 (REV. 02/2015) PAGE 2

74
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Get a doctor (primary care physician). Short Term Goal: Short Term Goal:
Goal Start Date: 08/15/2017 Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE
09/13/17:
5. Melody will call Bobby and
the Peer Support Specialist to
inform them of the date and
time of the doctor appointment.
09/15/17:
6. Melody will contact the clinic
to tell staff that Bobby will
make a number of visits to the
waiting room over the next two
weeks.
09/18/17:
7. Twice a week for two weeks
Bobby and the Peer Support
Specialist will sit in the waiting
room of the clinic increasing
the length of time he sits in the
clinic at each visit. At the first
visit Bobby will try to sit in the
waiting room for ten minutes.

DSHS 10-481 (REV. 02/2015) PAGE 3

75
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Get a doctor (primary care physician). Short Term Goal: Short Term Goal:
Goal Start Date: 08/15/2017 Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE
10/02/17:
8. Bobby will go to the clinic
and his new doctor will meet
him in the waiting room for an
introduction.
10/04/17:
9. Bobby will wait in the
waiting room with his Peer
Support Specialist and then go
in to the exam room for a brief
period of time. During this time
his doctor will come in to the
exam room to meet Bobby.

DSHS 10-481 (REV. 02/2015) PAGE 4

76
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Get a doctor (primary care physician). Short Term Goal: Short Term Goal:
Goal Start Date: 08/15/2017 Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE
10/10/2017:
10. The Peer Support Specialist
with transport Bobby to his
first appointment and his
doctor will do a brief exam.
10/11/2017:
11. Melody will call Bobby after
his appointment to check in.
Together they will discuss what
he learned from his doctor and
what he would like to do next.

DSHS 10-481 (REV. 02/2015) PAGE 5

77
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

DSHS 10-481 (REV. 02/2015) PAGE 6

78
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan Robert "Bobby" Smith 04/07/1969 999999999WA
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
Always There 360 111 -1111
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE
08/15/2017 08/15/2017 Ever So Helpful Melody Petrianado 360 111-2222
Initial / Annual HAP Four Month Update Eight Month Update
Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

DSHS 10-481 (REV. 02/2015) PAGE 7

79
Katz Index of Independence in Activities of Daily Living

80
 Link to Katz ADL video:
https://consultgeri.org/try-this/general-assessment/issue-2

Running time is 28:25 minutes

July 2016
81
 DEPRESSION SCREENING AND SUICIDE

GUIDE SHEET
OVERVIEW According to the National Institute of Mental Health, research suggests that people who have depression
and another medical illness tend to have more severe symptoms of both illnesses. They may have more
difficulty adapting to their co-occurring illness and more medical costs than those who do not have
depression. *The National Institute of Mental Health has identified the follow risk factors for
depression:
1. Personal or family history of depression
2. Major life changes, trauma, or stress
3. Certain physical illnesses and medications

Depression, even in the most severe cases, can be treated. Symptoms of depression include:
• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities
• Decrease energy, fatigue, being “slowed down”
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Restlessness, irritability
• Persistent physical symptoms
• Difficulty concentrating, remembering, or making decisions
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or
that do not ease even with treatment
• Thoughts of death or suicide, suicide attempts

Washington State has a goal to reduce hospitalizations due to suicide attempts and deaths due to
suicide. This guide sheet provides information about depression screening and suicide and was created
for Health Home Care Coordinators.

YOUR ROLE AS One service Care Coordinators (CCs) provide to clients is the opportunity to complete the Patient
A CARE Health Questionnaire – 9 (PHQ-9). The PHQ-9 is a screening assessment for depression. There are
COORDINATOR nine questions regarding mood and thoughts during the past two weeks.
How to administer and score the PHQ-9:
The CC may ask the client the nine questions, the client may complete the assessment, or a
reliable surrogate may answer the questions. The nine questions are scored using four options:
1. Not at all (scoring = 0 points)
2. Several days (scoring = 1 point)
3. More than half the days (scoring = 2 points)
4. Nearly every day (scoring = 3 points)

*Chronic Illness and Mental Health: Recognizing and Treating Depression. Bethesda, MD: National Institute of
Mental Health. Retrieved November 21, 2017 from
https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/nih-15-mh-
8015_151898.pdf

82
_
 The points are added up to determine the total score with a maximum of 27 points. Clients and
surrogates retain the right to decline to complete the assessment. Document in the client file who was
asked to complete the PHQ-9, the date, and the reason (if provided) that the PHQ-9 was not completed.
If the CC has concerns about potential depression for a client who has not completed the screening they
should ask the client if they may consult with their primary care or behavioral health provider. The
screening assessment should be offered to the client or surrogate at least one time during each four
month activity period. Scores of 10 or higher may indicate the need for more frequent screenings. CCs
should use their professional judgment to determine when to offer additional screenings.
Before you complete face-to-face visits and administer any screenings:
• Know and follow your agency’s policies related to responding to potential suicide.
• Effective April 2018 designated mental health professionals (DMHPS) were renamed
designated crisis responders (DCRs). Research your area’s Designated Crisis Responders
(DCRs) and keep these phone numbers with you while visiting clients.
o Use this link to locate DCRs in your area: https://www.hca.wa.gov/assets/billers-and-
providers/designated-crisis-responders-contact-list.pdf

ITS ABOUT THE First, ask for permission to have a conversation about depression:
CONVERSATION CCs might consider opening the conversation about possible depression:
• For example: “Depression often occurs with other diseases, such as _________________________.
I have a few questions I would like to ask to see if this might be happening with you. Would
you be willing to talk with me about this?”
If the client answers yes to the ninth question on PHQ related to suicide
*SAMHSA recommends asking these four questions about suicidal ideation:
• Past Suicide Attempt: “Have you ever attempted to harm yourself in the past?”
• Suicide Plan: “Have you had thoughts about how you might actually hurt yourself?” (This
could include thoughts of timing, location, lethality, availability of means, and preparatory
acts.) If yes, “Do you have the means to follow it through?”
• Probability (Perceived): “How likely do you think it is that you will act on these thoughts
about hurting yourself or ending your life some time over the next month?”
• Preventive (Protective) Factors: “Is there anything that would prevent or keep you from
harming yourself?”
If the client responds “no or in a manner indicating they are not at risk” to the above questions
then no further immediate action is needed. The client should be referred for an evaluation to
determine what is causing the elevated suicide question on the PHQ and a plan set up to address
whatever the identified issue is. Document the responses in the client file.
If a client responds “yes or in a manner that is concerning” to having a suicide plan with high
probability then a DCR should be contacted to evaluate the person further. Having a history of
suicide attempts is a concern if the attempts are recent or in addition with having a plan and the
intent to carry it out. Use of the Columbia Suicide Severity Rating Scale may be more objective and
easier to determine who is a concern and who needs an immediate referral to a DCR.
Determine who else needs to be notified (family, caregiver, or provider/s). You can break
confidentiality due to a safety concern.
Document the responses and any actions taken.

83
Page 2
 * Older Americans Behavioral Health Issue Brief 4: Preventing Suicide in Older Adults. (2012). Rockville, MD: Substance
Abuse and Mental Health Services Administration. Retrieved November 21, 2017 from https://www.ncoa.org/wp-
content/uploads/Older-Americans-Issue-Brief-4_Preventing-Suicide_508.pdf

NEXT STEPS • Make sure the client has signed the Participation Authorization and Information Sharing
Consent form indicating consent to disclose mental health information.
• For immediate crisis intervention call 9-1-1. Have the client’s address and phone number
available for your report.
• Stay with the client until a family member, client representative, DCR, emergency responder, or
law enforcement arrives.
• Consult with your supervisor either on the phone for emergencies or in person for non-
emergencies. Document the results of the screening and all actions taken.
• Follow up with phone calls or face-to-face visits with the client, family members, or client
representative to discuss outcomes from hospitalizations and/or treatment and counseling.
Using a person-centered approach review the Health Action Plan with the client to see if it
could be revised to include goals and actions steps to better manage depressive symptoms.

RESOURCES Chronic Illness and Mental Health: Recognizing and Treating Depression:
https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health
Columbia-Suicide Severity Rating Scale (C-SSRS): http://cssrs.columbia.edu/
Evaluation and Triage Card: Safe-T Card: https://adaa.org/sites/default/files/SMA09-
4432.pdf
National Suicide Prevention Lifeline: 1-800 273-8255 (TALK)
Patient Health Questionnaire – 9 (PHQ-9): https://www.phqscreeners.com/
SAMHSA Older Americans Behavioral Health Issue Brief 4: Preventing Suicide in Older
Adults: https://acl.gov/sites/default/files/programs/2016-
11/Issue%20Brief%204%20Preventing%20Suicide.pdf

84
Page 3
 1 Health Home Training Manual

Depression and the Patient Health Questionnaire (PHQ-9)

Begin this discussion by asking the individual one or more of following questions:

 How do you feel about life in general?

How are your spirits generally?
Do you find yourself avoiding being with people? If yes, why is that?

Then ask the individual if you can ask him/her some specific questions about how they
have been feeling over the last two weeks? If the individual you are assessing can read,
give them the PHQ-9 and ask them to complete the screening.

An alternative method of administering the PHQ-9 is to provide an index card with the
following responses on it. Tell them to answer each question you ask them, using the
following scale:
 Not at all ( Scoring = 0 Points)
 Several days ( Scoring = 1 Point)
 More than half the days (Scoring = 2 Points)
 Nearly every day (Scoring = 3 Points)

If they cannot read, you will have to repeat the scale to them after each question is asked,
so they can make their choice. Proceed by asking the following questions:

Over the last 2 weeks, how often have you been bothered by any of the following
problems?
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure, or have let yourself or your
family down
Trouble concentrating on things, such as reading the newspaper or watching
television
Moving or speaking so slowly that other people could have noticed. Or the opposite-
being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself in some way.

A score of (10) or more indicates possible depression on the PHQ-9.

Discuss with this individual that from their responses to the questions you just asked, it
appears they may be suffering from depression. If needed, reassure him/her that
Depression is a serious illness, not a moral weakness. Inform him/her that there are many
effective ways to treat depression. Ask the individual if they are interested in a referral for
diagnosis and/or treatment. The referral may be to the individual’s primary health care

1
January 2018
85
 2 Health Home Training Manual

provider or a mental health professional. Discuss with the appropriate caregiver (family,
AFH, Assisted Living Facility, etc.) if necessary. When the client’s depression score is 10
or more, document your discussion about a referral; if the client chooses to seek assistance
for any problem identified then document the date you referred the client and who is
responsible to follow through. If the client or others are responsible, the care coordinator
should contact the client within 30 days of the referral and document the outcome.

Surrogate Report of Depression Symptoms: A surrogate report of Depressive

Symptoms is to be used when the care coordinator concludes that a surrogate would be a
more reliable reporter of the client’s mood and emotional state or when the client refuses to
answer the questions. It may also be used when a client has Alzheimer’s disease * or other
types of Dementia that has progressed to a point where the client cannot relate pertinent
information. 30% of individuals who have Alzheimer’s disease also suffer with major
depression. Many of these individuals have symptoms that cause significant distress and
dysfunction to both the individual and the caregiver. Clients with these conditions are not
able to reliably respond to the questions themselves in the PHQ-9 depression screen
above. Research has shown that family (or other primary) caregivers are reliable
informants in reporting depressive symptoms.

As an introduction to this issue, ask the family (or primary) caregiver if they have observed
the individual you are assessing as having persistent sadness or crying, a sleep impairment
or a change in their appetite. Then ask the caregiver if you can ask him/her some specific
questions about how the individual they are caring for may have been feeling over the last
two weeks? Proceed by following the process below.

If the caregiver can read, give them the index card with the following responses on it.
Telling them they are to answer each question you ask them, using the following scale:

 Not at all ( Scoring = 0 Points)

 Several days ( Scoring = 1 Point)
 More than half the days (Scoring = 2 Points)
 Nearly every day (Scoring = 3 Points)

If they are unable to read, you will have to repeat the scale to them after each question
is asked, so they can make their choice.

Here is some additional information regarding depression and its impact on clients
with chronic health problems.

The National Institute of Mental Health (NIMH) commissioned the Harris survey. The
survey showed that: Lack of energy, recurrent thoughts of death and difficulty concentrating
were viewed by half of the medical providers polled as natural components of aging rather
than symptoms of depression. Tragically, accordingly to data cited in a recent NIMH report,
70 % of elderly people who commit suicide visit their family doctors within a month of their
death, and 39% have a medical encounter within one week of killing themselves, yet their
depression remains undiagnosed and untreated. 25 % of elderly individuals experience

2
January 2018
86
 3 Health Home Training Manual

periods of persistent sadness that lasts two weeks or longer and more than 20% report
persistent thoughts of death and dying. 20% of clients in nursing home are depressed.
More than ½ of the people polled, 75 years or older, believed that depression is a natural
part of the aging process. Additionally, 93% of all adults polled said they believed
depression is a normal side effect for those suffering from a medical condition. These
individuals believed there was little that could be done to impact this.

Depression is one of the most common and potentially dangerous complications

of every chronic illness. It is particularly common in those with:
 Recent heart attacks
 Hospitalized cancer patients
 Recent stroke survivors
 People with multiple sclerosis
 Parkinson’s Disease and
 Diabetes

Depression caused by chronic illness often aggravates the illness, especially if the
condition causes pain, fatigue or disruption in social life. Depression makes pain hurt
more. Depression impairs the immune system, which can hurt the body’s efforts to combat
chronic illness.

Note: The highest rate of completed suicide among all population groups is in older white
men who become excessively depressed and drink heavily following the death of their
spouse.

3
January 2018
87
 PATIENT HEALTH QUESTIONNAIRE-9
(PHQ-9)
Over the last 2 weeks, how often have you been bothered More Nearly
by any of the following problems? Several than half every
(Use “✔” to indicate your answer) Not at all days the days day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you are a failure or

0 1 2 3
have let yourself or your family down

7. Trouble concentrating on things, such as reading the

0 1 2 3
newspaper or watching television

8. Moving or speaking so slowly that other people could have

noticed? Or the opposite — being so fidgety or restless 0 1 2 3
that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting

0 1 2 3
yourself in some way

FOR OFFICE CODING 0 + ______ + ______ + ______

=Total Score: ______

If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?

Not difficult Somewhat Very Extremely

at all difficult difficult difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from
Pfizer Inc. No permission required to reproduce, translate, display or distribute.

88
 Body Mass Index Table

Normal Overweight Obese Extreme Obesity

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

Height
(inches) Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443

Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report.

89
 Body Mass Index Tools and Calculators

BMI Tools Online

http://www.cdc.gov/healthyweight/assessing/bmi/index.html

BMI Calculator for Children and Teens (2-19)

https://www.cdc.gov/healthyweight/bmi/calculator.html

BMI Calculator for Adults (20 and older)

https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_ca
lculator/bmi_calculator.html

Rev 1.2022
90
ALCOHOL USE QUESTIONS (AUDIT)
Drinking alcohol can affect your health and some medications you may take. Please help us
provide you with the best medical care by answering the questions below.

One drink equals:

12 oz. beer 5 oz. wine 1.5 oz. liquor (one shot)

Place an X in one box that best describes your answer to each question.

In the past 12 months… 0 1 2 3 4

1. How often do you have a drink containing  Never  Monthly  2 to 4 times a  2 to 3 times  4 or more
alcohol? or less month a week times a week
2. How many drinks containing alcohol do
 1 or 2  3 or 4  5 or 6  7 to 9  10 or more
you have on a typical day when you are
drinking?
3. How often do you have 5 or more drinks  Never  Less than  Monthly  Weekly  Daily or
on one occasion? monthly almost daily
4. How often during the last year have you
 Never  Less than  Monthly  Weekly  Daily or
found that you were not able to stop
monthly almost daily
drinking once you had started?
5. How often during the last year have you
 Never  Less than  Monthly  Weekly  Daily or
failed to do what was normally expected
monthly almost daily
from you because of drinking?
6. How often during the last year have you
 Never  Less than  Monthly  Weekly  Daily or
needed a first drink in the morning to get
monthly almost daily
yourself going after a heavy drinking
session?
7. How often during the last year have you
 Never  Less than  Monthly  Weekly  Daily or
had a feeling of guilt or remorse after
monthly almost daily
drinking?
8. How often during the last year have you
 Never  Less than  Monthly  Weekly  Daily or
been unable to remember what
monthly almost daily
happened the night before because of
your drinking?
9. Have you or someone else been injured  No  Yes, but not in  Yes, during
because of your drinking? the last year the last year
10. Has a relative, friend, doctor, or other
 No  Yes, but not in  Yes, during
health care worker been concerned about
the last year the last year
your drinking or suggested you cut down?
Add scores for each column, then add
across this row.
TOTAL

Date_________________________
SCORING:

91
Each response from the AUDIT has a score ranging from 0 to 4. The top of each column has a number.
That number equals the score value for responses in that column. After a patient has completed the
AUDIT, add up each column score, and then sum all five columns for the patient’s score. Below are the
scoring guidelines for the AUDIT.

Guidelines for Interpretation for AUDIT

Score Risk Level Intervention

0-6 (Female) Zone I Feedback and alcohol education

0-7 (Male)
7-15 (Female) Zone II Brief intervention
8-15 (Male)
16-19 Zone III Brief intervention plus brief therapy

20-40 Zone IV Brief intervention plus referral to chemical dependency treatment

Babor TF, Higgins-Biddle JC , Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test Guidelines for Use in
Primary Care. 2nd Edition. World Health Organization. 2001

92
93
94
95
96
97
My Falls-Free Plan Name: ____________________________ Date: _________

As we grow older, gradual health changes and some medications can cause falls, but many falls can be prevented.
Use this to learn what to do to stay active, independent, and falls-free.

Check “Yes” if you experience No Yes What to do if you checked “Yes”

this (even if only sometimes)

Have you had any falls in the last Talk with your doctor(s) about your falls and/or concerns.
six months? Show this checklist to your doctor(s) to help understand and treat
your risks, and protect yourself from falls.
Review your medications with your doctor(s) and your pharmacist
Do you take four or more at each visit, and with each new prescription.
prescription or over-the-counter Ask which of your medications can cause drowsiness, dizziness,
medications daily? or weakness as a side effect.
Talk with your doctor about anything that could be a medication
side effect or interaction.
Tell your doctor(s) if you have any pain, aching, soreness, stiffness,
Do you have any difficulty walking weakness, swelling, or numbness in your legs or feet—don’t
or standing? ignore these types of health problems.
Tell your doctor(s) about any difficulty walking to discuss treatment.
Ask your doctor(s) if physical therapy or treatment by a medical
specialist would be helpful to your problem.
Do you use a cane, walker, or Ask your doctor for training from a physical therapist to learn what
crutches, or have to hold onto type of device is best for you, and how to safely use it.
things when you walk?
Ask your doctor for a physical therapy referral to learn exercises
Do you have to use your arms to
to strengthen your leg muscles.
be able to stand up from a chair?
Exercise at least two or three times a week for 30 min.
Tell your doctor, and ask if treatment by a specialist or physical
Do you ever feel unsteady on your therapist would help improve your condition.
feet, weak, or dizzy? Review all of your medications with your doctor(s) or pharmacist
if you notice any of these conditions.
Has it been more than two years Schedule an eye exam every two years to protect your eyesight
since you had an eye exam? and your balance.
Has your hearing gotten worse Schedule a hearing test every two years.
with age, or do your family or If hearing aids are recommended, learn how to use them to help
friends say you have a hearing protect and restore your hearing, which helps improve and protect
problem? your balance.
Ask your doctor(s) what types of exercise would be good for
Do you usually exercise less than
improving your strength and balance.
two days a week? (for 30 minutes
Find some activities that you enjoy and people to exercise with
total each of the days you exercise)
two or three days/week for 30 min.
Do you drink any alcohol daily? Limit your alcohol to one drink per day to avoid falls.
Do you have more than three See your doctor(s) as often as recommended to keep your health
chronic health conditions? (such in good condition.
as heart or lung problems, diabetes, Ask your doctor(s) what you should do to stay healthy and active
high blood pressure, arthritis, etc. with your health conditions.
Ask your doctor(s) if you are unsure.) Report any health changes that cause weakness or illness as soon
as possible.

The more “Yes” answers you have, the greater your chance of having a fall. Be aware of what can cause falls, and take
care of yourself to stay independent and falls-free!

This material is in the public domain and may be reproduced without permission. If you use or adapt this
material, please credit the Washington State Department of Health, Injury & Violence Prevention Program. Reviewed by: ___________________
98
Four Things You Can
Do to Prevent Falls:
Learn More
Contact your local community or senior
Stay
1 Speak up.
center for information on exercise, fall
prevention programs, and options for Independent
Talk openly with your healthcare
provider about fall risks and prevention.
improving home safety, or visit:
Learn more about fall
• cdc.gov/falls
Ask your doctor or pharmacist to review
your medicines.
• www.stopfalls.org prevention.
2 Keep moving.
Begin an exercise program to improve
your leg strength and balance.
3 Get an annual eye exam.
Replace eyeglasses as needed.
4 Make your home safer.
Remove clutter and
tripping hazards.

1 in 4 people 65 and
older falls each year.

For more information, visit www.cdc.gov/steadi

This brochure was produced in collaboration with the following organizations:

VA Greater Los Angeles Healthcare System, Geriatric Research Education &
Clinical Center (GRECC), and the Fall Prevention Center of Excellence.

Prevent falls Centers for Disease

Control and Prevention
to stay injury-free National Center for Injury
Prevention and Control Stopping Elderly Accidents,
and independent. Deaths & Injuries
99
2023
Check Your Risk for Falling
Circle “Yes” or “No” for each statement below Why it matters

Yes (2) No (0) I have fallen in the past year. People who have fallen once are likely to fall again.

I use or have been advised to use a cane or People who have been advised to use a cane or walker may
Yes (2) No (0)
walker to get around safely. already be more likely to fall.

Unsteadiness or needing support while walking are signs of

Yes (1) No (0) Sometimes I feel unsteady when I am walking.
poor balance.

I steady myself by holding onto furniture

Yes (1) No (0) This is also a sign of poor balance.
when walking at home.

Yes (1) No (0) I am worried about falling. People who are worried about falling are more likely to fall.

I need to push with my hands to stand up

Yes (1) No (0) This is a sign of weak leg muscles, a major reason for falling.
from a chair.

Yes (1) No (0) I have some trouble stepping up onto a curb. This is also a sign of weak leg muscles.

Rushing to the bathroom, especially at night, increases your

Yes (1) No (0) I often have to rush to the toilet.
chance of falling.

Yes (1) No (0) I have lost some feeling in my feet. Numbness in your feet can cause stumbles and lead to falls.

I take medicine that sometimes makes me feel Side effects from medicines can sometimes increase your
Yes (1) No (0)
light-headed or more tired than usual. chance of falling.

I take medicine to help me sleep or improve

Yes (1) No (0) These medicines can sometimes increase your chance of falling.
my mood.

Symptoms of depression, such as not feeling well or feeling

Yes (1) No (0) I often feel sad or depressed.
slowed down, are linked to falls.

Add up the number of points for each “yes” answer. If you scored 4 points or more, you may be at risk for falling.
Total Discuss this brochure with your doctor.

To check your risk online, This checklist was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall
visit: www.bit.ly/3o4RiW8 risk self-assessment tool (Rubenstein et al. J Safety Res; 2011: 42(6)493-499). Adapted with permission of the authors.
100
101
102
103
 Health Action Plan (HAP) Assessment Guide
Note: All screening tools (required and additional) may be found in the 2-day training manual at:
https://www.dshs.wa.gov/sites/default/files/ALTSA/stakeholders/documents/duals/Trainers%20Manual/2%20Day%20training%20Manual.pdf
and the Care Coordinator Toolkit at: https://www.dshs.wa.gov/altsa/stakeholders/washington-health-home-program-core-training

Assessment Age When to Notes & Translations & Resources

Offer Considerations

PAM 18+ Required Required if CAM not Multiple languages available. Visit Phreesia/Insignia website.
present and client is
18 years or older.
CAM 18+ Required Required if PAM not Multiple languages available. Visit Phreesia/Insignia website.
present and client is
18 years or older.
Caregivers may be
informal or formal
caregivers
P-PAM Under 18 Required Required if client is Multiple languages available. Visit Phreesia/Insignia website.
less than 18 years of
age. If client is 18
years or older, field
is not required on
HAP and no data is
accepted. Parents
include: Biological,
adoptive, or foster.
Katz ADL 18+ Required If a client indicates https://hign.org/consultgeri/try-this-series/katz-index-
that they are independence-activities-daily-living-adl

Rev 11.20.2023
104
 dependent and
could use assistance
with two or more
ADLs consider a
discussion about
applying for LTSS (or
follow-up with case
manager on
changes if client
already has LTSS).
If client is less than
18 years of age, field
is not required on
HAP and no data is
accepted. For
minors, discuss any
need for ADLs with
parent/ guardian
and if referrals are
needed (e.g. DDA)
PHQ-9 18+ Required Score of 10 or Multiple languages available
higher indicates https://www.phqscreeners.com/select-screener
potential
depression. Have
discussion with
client. Do they
receive treatment, is
a referral needed,
share elevated
scores with PCP or
BH provider.

Rev 11.20.2023
105
 “Yes” on question 9
(suicide) would
result in action
PSC-17 4-17 Required Completed by Multiple languages available
parent/guardian. https://www.massgeneral.org/psychiatry/treatments-and-
A child age 13 and services/pediatric-symptom-checklist/
over may self-
administer the
screening. Total
score of 15 or
higher, or any
subscale score
exceeding the cut-
off should lead to
referral to
behavioral health
provider or back to
PCP for further
assessment.
Subscales
• Internalizing-
anxiety & mood
disorder, cut-off
score 5
• Attention-
hyperactivity,
attention deficit,
cut-off score 7
• Externalizing –
conduct problems,
oppositional
behavior, cut-off
score 7

Rev 11.20.2023
106
 BMI 2+ Required Anything below 18.5 BMI tools online
or 25 and above as http://www.cdc.gov/healthyweight/assessing/bmi/index.html
score considered BMI Calculator for Children and Teens (2-19)
outside of healthy https://www.cdc.gov/healthyweight/bmi/calculator.html
BMI Calculator for Adults Adult BMI Calculator | Healthy
Weight, Nutrition, and Physical Activity | CDC
DAST 16+ When Score of 1 and English
indicated above may indicate https://sbirt.publichealthcloud.com/resources/links/DAST-
a need for 10%20Revised.pdf
intervention. Spanish (some differences including 6 month lookback & 4
If there is an more items
elevated score, the https://elcentro.sonhs.miami.edu/research/measures-
focus is getting library/dast-10/dast-10_spa.pdf
clients to the
appropriate DBHR: https://www.hca.wa.gov/health-care-services-
professional or supports/behavioral-health-recovery/substance-use-
resource. treatment#type-of-services
GAD-7 12+ When Score of 10+ may Multiple languages available
indicated indicate anxiety. https://www.phqscreeners.com/select-screener
Discuss with client,
notify PCP or BH
provider of elevated
score
AUDIT 14+ When A score of 8 or more Multiple languages available
indicated may indicate a need https://auditscreen.org/translations
for intervention. • DBHR: https://www.hca.wa.gov/health-care-services-
If there is an supports/behavioral-health-recovery/substance-use-
elevated score, the treatment#type-of-services
focus is getting • AUDIT : the Alcohol Use Disorders Identification Test :
clients to the guidelines for use in primary health care (who.int)
appropriate

Rev 11.20.2023
107
 professional or • Drinking Levels Defined | National Institute on Alcohol Abuse
resource. and Alcoholism (NIAAA) (nih.gov)
• Screening, Brief Intervention, and Referral to Treatment (SBIRT)
| SAMHSA
• Alcohol Use Disorders Identification Test (AUDIT) | SAMHSA
• How to Start Drinking Less | CDC
Falls Risk 18+ When 0 to 2 indicates a English version My Falls-Free Plan (wa.gov)
indicated low risk for falls • Fall Prevention Resources Fall Prevention Resources |
Washington State Department of Health
2 to 4 indicates a • Check for Safety (CDC)
moderate risk for https://www.cdc.gov/steadi/pdf/check_for_safety_brochure-
falls a.pdf
4 or more indicates • What YOU Can Do To Prevent Falls (CDC)
https://www.cdc.gov/steadi/pdf/STEADI-Brochure-
a high risk for falls
WhatYouCanDo-508.pdf
• AARP HomeFit Guide is a room by room guide to modifying
homes for safety (AARP) http://www.aarp.org/livable-
communities/info-2014/aarp-home-fit-guide-aging-in-
place.html
FLACC When self When A score of 4 or Find English version on the Care Coordinator toolkit
(Behavioral report not indicated above indicates a
possible. For moderate level of
pain
ages 2 pain that may
assessment months to 7 interfere with
scale years, or if an activities of daily
individual is living. Discuss
not able to results with client,
communicate notify PCP of
pain level elevated score.
Wong- Use with When A score of 4 or Multiple languages available
Baker adults and indicated above indicates a http://www.wongbakerfaces.org/faces-download/
children 3 moderate level of
FACES

Rev 11.20.2023
108
 (pain rating years and pain that may
scale) older interfere with
activities of daily
living. Discuss
results with client,
notify PCP of
elevated score.
Numeric Adults and When A score of 4 or Find English version on the Care Coordinator toolkit
(pain scale) children 9 indicated above indicates a
years and moderate level of
older pain that may
interfere with
activities of daily
living. Discuss
results with client,
notify PCP of
elevated score.

Rev 11.20.2023
109
 Sample Telephone Outreach Script

Note: this is a sample outreach script that may be used or edited for first
telephone contacts with your clients. Use of this script is not required.

Hi __________________, this is _______________ with _________________, here in __________

(county or town). Am I speaking with ____________________?

I am calling because you can now receive a free additional program as a part of your Medicaid
health insurance. Do you have a minute so I can tell you about it?
Good, the program I am calling about is the Health Home Program. The program helps clients to
support them so they can better manage the health care they receive and increase wellness. What
has made the program so successful is the support we offer. You do not need to come to
appointments; we can meet you in your own home or another place of your choice, such as an
office in your community or coffee shop.
Some of the things we have helped clients with is applying for housing and accessing resources
such as low-cost or free services like dental care and eyeglasses.
Would you like to schedule a time for me to meet with you so I can tell you more about the
program?
Are there days or times that work better for you? (Offer an appointment day and time.)
This is the address I have for you ____________________________.
Would you like me to meet you at this address?
Are there any other phone numbers I can reach you at?
Is there someone else, like a family member, that you would like to be at the visit?
Do I have your permission to contact them?
May I have their contact information?
Thanks for your time today. I look forward to meeting you on __________________ at
__________.
If something comes up and you need to reschedule you can reach me at ___________________.
My name is ____________________________. I can wait if you want to write this information
down.
Thank you for scheduling a visit. Do you have any questions I can answer now? Okay, goodbye.

January 2018
110
Qualified Health Home Lead Requested Disenrollment – Due Diligence
When a Qualified Health Home Lead, Care Coordination Organization or Care Coordinator is unable to
contact a client, the Lead and HCA must follow standardized procedures to disenroll the client from the
Health Home program

Due Diligence Process:

Qualified Health Home Leads (Lead) and HCA must follow these procedures when processing client disenrollments.
The Lead must ensure Due Diligence is followed to contact the client. All contacts and attempted contacts must
be documented in the client’s case file.

Step 1. Mail an HCA approved welcome letter prior to calling the client. If the letter is returned, the Lead/CCO
must check alternate databases or resources to secure an updated address and mail a second welcome letter to
the new address.

Step 2. HCA requires at least three (3) calls be attempted and documented. The calls must be made on different
days of the week and at different times of the day. At least one call must be made each month for two (2)
months following the initial attempts.

Step 3. If the client cannot be contacted after 90 days from the effective date of enrollment and the above
procedures have been followed, the Health Home Lead may request disenrollment of the client from the Health
Home Program according to the Disenrollment Process below.

For Previously Engaged Clients: The due diligence process may begin after one month of attempted contacts to
meet the monthly face- to-face home visit requirement. Example: Face-to-face meeting with client in August,
unable to contact client in September, begin the due diligence process in October starting with Step 2 above.

NOTE: Do not send the HCA Opt-out Form unless specifically requested by the client.

Disenrollment Process:

 CCO or Lead - If the CCO is unable to connect with the client following the above activities, inform the Lead.
 Lead - If the Lead determines the client should be disenrolled from the Health Home program, the Lead will:
o Send the Health Home Disenrollment letter to the last known address of the client giving the client at
least ten (10) business days to reply. Place a copy into the clients file.
o If the client contacts the Lead and wants to participate in the program before the disenrollment is
effective, the Lead must reassign them via a “warm hand-off” to a CC.
o If there is no response to the letter, fill out the Health Home Due Diligence Registry, which is to be
submitted monthly to HCA via secure email. Note that the Health Home Due Diligence Registry does
not replace the required documentation in the client’s case file
 HCA - When HCA receives the Health Home Due Diligence Registry from the Lead, the client’s Health Home
segment will be ended and enrollment terminated.

NOTE: A Due Diligence Disenrollment from the Health Home program is not considered an Opt-Out. If the client asks
to be reenrolled and meets Health Home eligibility criteria, they will be reenrolled. If after one year the client meets
the Health Home eligibility criteria, they may be passively reenrolled.

Due Diligence Guide Updated 11/08/17

111
Decisional Balance Scale
Value/Benefit of Staying the Same Value/Benefits of Changing

Disadvantage/Consequence of Disadvantage/Consequence of
Staying the Same Changing

112
 Questions to Consider
How important is it for you right now to...? On a scale from 0 - 10... what number would you
give yourself?
0_________________________________________________________________________10
CONVICTION/IMPORTANCE SCALE

If you did decide to change, how confident are you that you would succeed? On a scale from 0 - 10... what
number would you give yourself?
0_________________________________________________________________________10
CONFIDENCE SCALE

If you did decide to change, how ready are you to make this change? On a scale from 0 - 10...
what number would you give yourself?
0_________________________________________________________________________10
READINESS SCALE
113
 Non-Emergency Medical Transportation (NEMT) for Health Home Services
REQUEST FORM
Date:

TO NEMT Broker: FAX #:

NEMT Broker Look-up: https://www.hca.wa.gov/assets/billers-and-providers/BrokerByCounty.pdf

FROM (Care Coordination Organization):

Name of Care Coordinator: Phone #

Health Home Lead Agency: (Check one)

____AAADSW ____Northwest Regional Council
____Amerigroup ____Olympic AAA
____Community Choice – Action Health Partners ____Pierce County Human Services (AAA)
____Community Health Plan of WA ____Pierce County ACH
____Coordinated Care ____SE WA AAA
____Full Life Care ____United Health Care
____Molina

Section I - Client Information

Last Name First Name

ProviderOne ID Number DOB:

Transportation Date (mm/dd/yyyy) and *Appointment Time:

Pick-up Address (exact address/entrance):

Drop-off Address (exact address/entrance):

ROUND TRIP (Circle one): YES / NO

Special Needs (e.g. escort; oxygen, wheelchair/oversize wheelchair; etc.):

Section II – Certification:

Client is Medicaid Eligible Client is enrolled with the Health Home Lead selected above
Client needs transportation to an alternate location to receive health home services

Care Coordinator Signature/Date: / 114

 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) FOR HEALTH HOME CLIENTS
Beginning April 1, 2015, transportation may be provided to Health Home clients for services
when the client is homeless or lives in an unhealthy or unsafe environment. A Care Coordinator
may request a non-emergency medical transportation to alternate locations to conduct care
coordination services such as developing the Health Action Plan (HAP), obtaining consent to
participate, or to administer health assessments.
TO USE NEMT SERVICES:
1. Only the Care Coordinator can request NEMT for the Health Home client. The client
must behaviorally and medically stable and safe to transport.

2. The Care Coordinator must identify an alternate location where he/she may meet the
client in person. Examples of acceptable alternate locations include but are not limited
to:
• A medical office or behavioral health setting or
• A community based social or health services location such as senior center,
community services office, Area Agency on Aging, or local health department.

3. The Care Coordinator must ensure the availability of the alternate location prior to
scheduling the transportation.

4. NEMT for clients can only be used when providing a qualifying Health Home service and
is limited to the following distance standards:
• Within 10 miles of the client’s residence in urban or suburban areas or
• Within 25 miles of the client’s residence in rural areas.
Exceptions may be made to the distance criteria on a case-by-case basis in remote areas
of the state and by approved by HCA. To request an exception, the Health Home Lead
Entity with whom the client is enrolled must request the approval by sending an email
to [email protected] and include the client’s name and ProviderOne ID as well
as the reason for the exception.

5. The Care Coordinator must complete the Request Form for Non-Emergency Medical
Transportation (NEMT) for Health Home Services and fax to the NEMT broker and
maintain a copy in the client file for audit purposes.
A list of contracted regional transportation brokers can be found at
https://www.hca.wa.gov/assets/billers-and-providers/ContractedBrokers.pdf.

UPDATED 12.27.2021

115
 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) FOR HEALTH HOME CLIENTS
FREQUENTLY ASKED QUESTIONS (FAQs)
Beginning April 1, 2015, transportation may be provided to Health Home clients for services when the
client is homeless or lives in an unhealthy or unsafe environment. A Care Coordinator may request a
non-emergency medical transportation to alternate locations to conduct care coordination services such
as developing the Health Action Plan (HAP), obtaining consent to participate, or to administer health
assessments.

WHAT IS THE HEALTH HOME PROGRAM?

The Health Home program is a care coordination service available to eligible Medicaid clients of all ages
including Medicaid clients who also receive Medicare. To receive services, clients must have a chronic
condition and be at risk for a second, as demonstrated by a PRISM risk score of 1.5 or greater. The
program focuses on care coordination between the client’s medical, behavioral, and social needs
providers.

WHO IS THE CARE COORDINATOR?

A Care Coordinator is the person who provides Health Home services. The Care Coordinator works with
clients to help them identify and meet their goals for self-management, improving health, and providing
comprehensive care management.

WHY WOULD A HEALTH HOME CLIENT NEED NEMT?

Health Home care coordination is person-centered and based on the development of the Health Action
Plan (HAP) by the Care Coordinator and the client. The development of the HAP, as well as some
ongoing Health Home services, require face-to-face visits that usually takes place in the client’s home. If
a client is homeless or lives in an unhealthy environment, the Care Coordinator may identify an alternate
location for the face-to-face visit. In these instances, the client may need transportation to the alternate
location.

WHO CAN REQUEST NEMT?

Only a client’s Care Coordinator can request NEMT services from a transportation broker for providing
Health Home services. Clients may not schedule this service. The Care Coordinator must contact the
NEMT broker available in the client’s county of residence and submit a NEMT Health Home Services
Request Form. The list of transportation brokers is available at https://www.hca.wa.gov/assets/billers-
and-providers/ContractedBrokers.pdf.

WHAT ARE ACCEPTABLE ALTERNATE LOCATIONS TO USE NEMT FOR HEALTH HOME SERVICES?
The Care Coordinator must identify an alternate location where the client may be met in person.
Examples of acceptable alternate locations include but are not limited to:

• A medical office or behavioral health setting or

• A community based social or health services location such as senior center, community services
office, Area Agency on Aging, or local health department.

UPDATED 12.27.2021

116
WHAT ARE THE DISTANCE STANDARDS FOR TRANSPORTATION OF HEALTH HOME CLIENTS?
NEMT for Health Home services is limited to the following distance standards:

• Within 10 miles of the client’s residence in urban or suburban areas or

• Within 25 miles of the client’s residence in rural areas.

Exceptions may be made to the distance criteria on a case-by-case basis in remote areas of the state and
be approved by HCA. To request an exception, the Health Home Lead Entity with whom the client is
enrolled must request the approval by sending an email to [email protected] and include the
client’s name and ProviderOne ID as well as the reason for the exception. HCA will notify the Health
Home Lead Entity and the transportation broker of approved exceptions to the distance standards.

HOW DOES THE CARE COORDINATOR KNOW WHEN THE NEMT IS SCHEDULED?

The NEMT broker will contact both the Care Coordinator and the client when the request for the trip is
approved and scheduled.

WHERE CAN I FIND MORE INFORMATION?

Health Home services website: https://www.hca.wa.gov/billers-providers-partners/programs-and-
services/health-home-resources

HCA Transportation website: https://www.hca.wa.gov/billers-providers-partners/programs-and-

services/transportation-services-non-emergency

Transportation brokers: https://www.hca.wa.gov/assets/billers-and-providers/ContractedBrokers.pdf

Email questions to: [email protected]

UPDATED 12.27.2021

117
Dear Administrator or Staff,
I am a Health Home Care Coordinator with _________________________.

I am here because one of your residents is eligible for the Health Home
Program. The program is voluntary and is provided at no cost to eligible
Medicaid and Medicaid/Medicare clients. The state identified one or more
of your residents who are eligible to receive my services.

The Health Home Program helps residents who have one or more chronic
diseases. These residents are at risk for other health problems and higher
medical costs.

Care Coordinators help your resident(s) create a Health Action Plan, which
includes personalized health goals. I can assist you by providing Health
Home activities such as:
1. Teaching your resident about their health
2. Coaching family members to support your resident and you
3. Referring your resident to services outside of routine care
4. Helping you with care transitions when your resident returns from a
hospital or nursing facility

Your resident may receive monthly visits and phone calls as part of their
Health Home services. I look forward to working with you to support your
resident in reaching their health goals.

Optional Use by Facility

Resident Name ID#

118
 Best Practices Residential Facilities

• Follow facility sign in/out procedure

• Attempt to adhere to reasonable visiting hours

• Understand basic workings of Residential facilities and roles of staff

• Prearrange visits and private space for meetings

• Provide Residential Introduction Letter to staff

• Provide your business card (if available)

• Wear appropriate organization identification

• Attain contact information of staff

• Be mindful of staff’s duties and time. They have multiple residents they tend to

• Do not go into resident rooms without asking the resident first. Always knock first and

wait for response before entering their room. Residents may be in shared rooms

• Ask the client, when applicable, if they would like you to attend their annual CARE

assessment

• Notify, when applicable, your client’s HCS/AAA/DDA worker for care coordination

• Bring general Health Home program educational materials to leave with resident and

facility staff as applicable

119
 Best Practices Skilled Nursing Facilities

• Follow facility sign in/out procedure

• Attempt to adhere to reasonable visiting hours

• Understand basic workings of Skilled Nursing Facilities. It is helpful to know when client

is scheduled for therapy or medical visits, meal times, shift changes, activities and other

schedules that may impact having quality time with your client

• Prearrange visits and private space for meetings

• Provide Residential Introduction Letter to staff

• Provide your business card (if available)

• Wear appropriate organization identification

• Attain contact information of staff

• Be mindful of staff’s duties and time. This is a nursing/rehab facility which operates 24

hours per day and which staff have multiple residents they tend to

• Do not go into resident rooms without asking the resident and nursing home staff first.

Always knock first and wait for response before entering room. Residents may be in

shared rooms

• Ask the client, when applicable, if they would like you to attend their care conference or

other multidisciplinary team meeting

• Notify, when applicable, your client’s HCS/AAA/DDA worker for care coordination

• Bring general Health Home program educational materials to leave with resident and

facility staff as applicable

120
Interpreter Service Program Overview
Interpreter Service (IS) is a program available through Health Care Authority (HCA) for Medicaid health care providers
and their Medicaid clients. The program allows the providers to gain access to skilled and qualified spoken language
access providers (LAPs) and sign language interpreters for Apple Health (Medicaid) clients who have limited English
proficiency (LEP) and may be Deaf, DeafBlind, or hard of hearing. HCA offers access to an in-person spoken language
contract, an over-the-phone and video remote spoken language contract, and a sign language contract. The IS program
works with Universal Language Service for all spoken language contracts and the Office of Deaf and Hard of Hearing
(ODHH) for the sign language contract.

Medicaid providers are required to ensure appropriate language access is provided to their Medicaid clients according to
Title VI of the Civil Rights Act of 1964 and the Americans with Disabilities Act (ADA).

How to request an Interpreter or LAP?

• Request spoken language LAPs through our contract with Universal Language Service.
• Request sign language interpreters through the Department of Enterprise Services (DES) Office of Deaf and
Hard of Hearing (ODHH) master contract utilizing the online request system.

Who is eligible to utilize HCA’s Interpreter Services contracts?

Apple Health Medicaid providers are eligible to request an interpreter when:
• They have a national provider identification number (NPI)
• They are actively enrolled as an Apple Health Medicaid enrolled health care provider
• The services are for an eligible Apple Health Medicaid client

What services are available through Universal Language Service?

• Universal Language Service offers in-person, over-the-phone, and video remote interpreting. All appointments
are offered to DSHS certified, authorized, and recognized LAPs. Medicaid providers can schedule a service
request online through the Universal Language Service portal.
• It is the responsibility of the provider to verify eligibility, but Universal Language Service will verify the
eligibility when accepting the request for interpreter services.
• LAPs are paid directly by Universal Language Service so there is no paperwork for providers.

What services are available through DES/ODHH?

• ODHH offers interpreter services with certified, authorized, and recognized sign language and tactile
interpreters.
• Increased ability to best match interpreters with Deaf, DeafBlind, and Hard of Hearing clients.
• Accepts requests through the online request system.

For more information on Interpreter Services please visit the Interpreter Services webpage.
Contact us at: [email protected]

HCA Interpreter Service Overview 12-2022

121
HCA Interpreter Service Overview 12-2022
122
 Go to Client and select Benefit Inquiry

We will review a few screens in ProviderOne Benefit Inquiry that show

how to identify clients that are eligible for the Health Home program.

At the end of this module there will be a handout of these screens for
future reference.

Some of you may not receive access to ProviderOne. Check with your
agency and Lead if you will be gaining access.

In many cases you will not be able to tell for sure that a client is eligible,
but by understanding the Benefit Inquiry screen you will be able to answer
some eligibility questions.

Go to the Client tab in ProviderOne and select Benefit Inquiry.

123
 Enter information available to identify the client

Enter what information that you have available to identify the client.

124
 In this example, all sections are closed. Note: There is no Health Home
Eligibility section, so we already know the client is not currently
documented as eligible for Health Home

In this example, all sections are closed so that you can see this client does
not have a Health Home section.

This means that the client has not been identified as Health Home eligible
or they are not currently eligible. A client could however be identified as
eligible in the future.

125
 Here is a client with a Health Home Eligibility screen

Here is a client with a Health Home eligibility screen and has a Health
Home segment entered into their profile.

Although this tab is titled Health Home Eligibility, It takes more than just a
Health Home segment to make a client eligible.

126
 In this example, the client was made Health Home eligible starting
10/1/2013 and continues to be eligible as the end date is in the future

In this example, the client was made Health Home eligible starting
10/1/2013 and continues to be eligible as the end date is in the future.

127
 Same client continued

Let us look at other information on this client.

In the Managed Care Information section, we see that the client is

receiving Health Home services through Northwest Regional Council –
Health Home Only program. Note that the start date is in the past and the
end date is in the future.

Health Home services are never received through a Behavioral Health

Services Only contract such as the one listed here. This is also true with
Employment, Housing PACE and PCCM programs.

There must be a separate line that mentions Health Home. There may also
be different organizations providing different services such as in this
example.

128
 Same client continued

Here is the Client Eligibility Spans information for the same client.

For a non-managed care Fee-For-Service client to be Health Home eligible

they must have a CNP or ABP Benefit Service Package (Categorically Needy
or Alternative Benefit Program). If eligible, they may be enrolled with a
Health Home Only provider.

Also, note the start and end date.

129
 Managed Care Client example

Here is an example of a client in Apple Health managed care (Fully

Integrated Managed Care) with a Benefit Services Package of ABP.
Managed care clients may also be CNP.

130
 PRISM Data Fields – CARE

The Predictive Risk Intelligence SysteM contains valuable information designed to support care
management interventions for high-risk clients. It includes information from medical, social
service, behavioral health and long term care payments including assessment data from CARE.
Information includes Medicare and Medicaid claims, in-patient stays, Emergency Department
utilization, and risk factors. The lookback period for data is 15 months for adults and 24 months
for children. The following shows the types of data CARE exports to PRISM.

Long Term Care Assessments: In PRISM, the entire CARE assessment is not available, however
it will show the history of assessments. It lists the type (annual, interim, sig change, initial),
status (current, pending, history), Date assessment was done, and the Problem Description. The
Problem description is taken verbatim from “reason for assessment” on the CARE Assessment
Main screen. When the PRISM user selects a particular assessment from the list, the following
information will display:
Behaviors: The number of behaviors are displayed and when the PRISM user clicks on this
section, it shows the name of behavior, type of behavior, status (current/past), intervention,
alterability, and description.
Fall: Provides the number of falls listed and when the PRISM user clicks on this section, it shows
site (e.g. bedroom, outside), and when occurred (e.g. within 30 days, past 31-180 days).
Pain: The number provided is not the client’s pain level but rather the amount of impacts listed
for pain. When the PRISM user clicks in this section, it specifies the pain impacts (e.g.
depression, activity limited, sleep loss, etc.).
Limitations: The number listed is the amount of limitations that are on the assessment. When
the PRISM user clicks on it, it shows each limitation from all screens.
Client: Shows ADSA ID, name, reporting unit and housing (does not pull the address).
Worker: Shows current HCS/AAA/DDA case manager and their phone number per overview
screen.
PCP: Shows name, address and start date of any PCP’s listed as PCP in contact role. Will show
previous PCP’s with end date.

Other details: The following areas show only the noted response and no further information:
ADL Score (0-28): Does not list the ADL’s but only shows the score (0-28);

BV 12.2023
131
 Depression Score: Lists the depression score by number. CARE uses the Patient Health
Questionnaire (PHQ), PHQ-2/PHQ-9, a validated depression screening tools to assist in
the assessment process. The PHQ-0 is also used in MDS 3.0 and will allow for
comparisons across healthcare settings. A score of 10 or more indicates possible
depression and the case manager is to document a discussion regarding possible
referral;
CPS Score (0-6): Lists the CPS score (0-6). The Cognitive Performance Scale (CPS) is made
up of the following elements taken from the assessment:
• Is client comatose?
• Can client feed her/himself?
• Can client make her/him understood?
• Rate how client makes decisions
• Short term memory OK? Or MMSE delayed recall (missing one or more)
The following table contains the average relationship between a client’s CPS and MMSE
score.

Score meaning Cognitive performance scale

Intact 0
Borderline Intact 1
Mild Impairment 2
Moderate Impairment 3
Moderate to Severe Impairment 4
Severe Impairment 5
6
Very Severe Impairment

Overall Self-Sufficiency: Lists what was selected on Independence and Improvement

screen (e.g. No change, Deterioration, Improved);
Self Rated Health Status: Lists what was selected on the Indicators/Health Indicators
screen (e.g. good, fair, poor). This question is an excellent indicator of a client’s health
status. A client’s perspective of his/her health can be a very good predictor of what
his/her health status will be;
Residential Group: From the Care Plan screen lists the Classification such as A High, B
Low, etc. This is the clinical grouping that the client falls into based upon clinical
complexity, Cognitive Performance Scale (CPS) score, moods/behavior, and ADL score;
and
In Home Group: Same as Residential Group.

BV 12.2023
132
Finding Case Manager Contact Information in PRISM
If a Care Coordinator is having difficulty getting in contact with a client, they may want to see if
there is a case manager assigned who may have current contact information. Speaking with
case managers may also help with coordinating services for clients.
To find if there is a case manager with HCS/AAA/DDA go to the CARE tab in PRISM. If there is an
assessment, it will show under “Long Term Care Assessments”. Assessments will be listed as
current, pending or history. If there is no assessment, or if the most recent assessment is listed
as “history”, the client may not have a current case manager.

133
When the PRISM user selects a particular assessment from the list, the following information
will be displayed

Click on “Worker”. Once you do, the current HCS/AAA/DDA case manager and their phone
number will be shown.

134
 CARE COORDINATOR ADVANCE CARE PLANNING (ACP) GUIDE SHEET
OVERVIEW Determining our preferences for health care, medical emergencies, disability, and end
of life care poses a challenge not only for ourselves but also for our clients, parents,
caregivers, and family members.

Advance Care Planning (ACP) is a process in which an individual explores their goals,
values, and beliefs and considers what health care they would want in their future,
including wishes and preferences for care at the end of life. It involves choosing a
health care agent who can communicate their wishes if they can no longer speak for
themselves, and having conversations with their loved ones about their choices.

An Advance Directive (AD) is a legal document that includes two parts: a health care
directive for documenting client treatment wishes and a durable power of attorney for
health care used to name their selected health care agent (HCA).

YOUR ROLE AS One service Care Coordinators (CCs) are required to provide is the opportunity for clients to consider
A CARE and discuss ACP. While CCs do not draft ADs for their clients they should assist clients and their families
COORDINATOR in accessing legal assistance if they wish to complete an AD. A discussion about ACP must be offered
within the first year of the client’s agreement to participate in the Health Home program. CCs are
expected to simply begin the conversation to determine the client’s interest in ACP. This offer of
assistance and any actions taken should be documented in the client’s case record.

ITS ABOUT THE CCs might consider opening the conversation in the following ways:
CONVERSATION First, ask for permission:
 Introduce ACP as a statewide initiative. We are talking with our clients about
the importance of ACP and ADs to help them and their families learn how to
plan for future health care decisions. Would you mind if we talked a bit about
this?
Second, consider these questions to assist the client in thinking about ACP:
 You may have received information about ACP. Tell me what you understand
about this type of planning? [The CC should confirm knowledge or provide
clarification about ACP and ADs.]
 Do you have any concerns about this planning? What experiences have you had
with family or friends who have become seriously ill or injured? [The CC should
be prepared to listen for experiences that will help the client think about their
personal goals and values regarding decision making. Promote dialogue by
asking “what did you learn from that experience?” “What else did you learn?”]

135
_
  Do you have questions about the role of an HCA? [The CC should be prepared to
review the qualities of an HCA including – does the HCA accept their role; does
the HCA accept the client’s goals, values, and preferences; does the HCA agree to
follow their wishes even if they do not agree with them; and can the HCA make
decisions in difficult moments?]

SUMMARY OF Summarize the three decisions that need to be made as part of ACP:
THE THREE  Who your health care decision maker or HCA should be;
DECISIONS
 What cultural, religions, spiritual, or personal beliefs you have that might
FOR ACP impact your decisions, and discuss these with your HCA and loved ones; and
 What health care would you like to receive if you have a sudden illness or
injury?

NEXT STEPS  Offer assistance with getting more information about ACP or connecting them to someone who
could help them complete an AD.
 If the client is interested in incorporating ACP or the development of an AD in to their Health
Action Plan ask the following questions:
 Would they like to set a short term goal of pursuing an AD?
 What action steps are necessary?
 Who will complete them and by when?
 Who else should be involved?
 Who should be informed that they are pursuing an AD?
 Who should receive copies of any documents created?

RESOURCES Health Home Care Coordinators Toolkit website located at:

https://www.dshs.wa.gov/altsa/stakeholders/chronic-disease-and-education-
materials

136
Page 2 Revised January 2018
 Family
Caregiver
Hospital-to-Home
Guide
Discharge Guide

In the Hospital: Planning for Discharge

A good way to start planning for discharge is by asking the doctor


The best time to start
how long your family member is likely to be in the hospital. The
doctor may know this when the admission is planned, such as for
surgery or tests. But the doctor may not know how long your
family member will be in the hospital if the admission was not
planning for discharge is
planned, such as for an emergency or sudden illness. When
just after your family
patients leave the hospital they might be discharged to:
member is admitted.
While it may seem too  Home, with no needed services
soon to think about going
 Home, with help needed from a family caregiver
home, planning gives you
more time to prepare.  Home, with help needed from a home care agency
 A rehabilitation setting (such as a short-term unit in a nursing
home or rehab facility)

www.nextstepincare.org ©2014 United Hospital Fund 1

137
 Home Care

Know Who Is on the Discharge Team

Many people help plan a hospital discharge, and they are often
referred to as a “team.” The team members include:
 A doctor. He or she authorizes (approves) the hospital
discharge.
 A nurse or social worker. This person coordinates the
discharge, making sure that everything happens when it
should. He or she also takes care of many details about hospital
discharge.
 You, the family caregiver. You likely are the one who knows
your family member best.
Tell the nurse or social worker that you are the family
caregiver. Meet with this person as soon as you can to talk
about discharge. This is a good time to discuss:
 How much time you can devote to being a family caregiver
 Whether you will provide all or some of the needed care
 Whether you can continue to work at your job or must take
time off
 Whether you have any health problems or other limitations,
such as not being able to lift heavy weights
 Whether you have other commitments, such as caring for
young children
 All your other questions and concerns about being a family
caregiver

www.nextstepincare.org ©2014 United Hospital Fund 2

138
 Home Care


Your family member
Help Decide about Discharge
You may feel pressure from the hospital team to take your family
should not leave the member home. Your family member might also pressure you to
rehab facility until there go home as soon as possible. Being home might be better for
is a safe and adequate everyone involved. But it needs to make sense for both your
discharge plan. This family member and you. This means that the home to which your
means that the plan meets family member will be discharged is safe, has a telephone, and
your family member’s does not need a lot of repair. It also means thinking about how to
needs and that you can do pay for care and balance caregiving with your other
what’s expected of you. commitments.
This is a lot to think about. You may need time to figure out how
to manage it all. Tell the team if you are not ready or able to
care for your family member after discharge. They will try to
help you solve the problem(s).

Appeal a Hospital Discharge Decision (if

needed)
Sometimes the hospital makes a discharge plan you do not want,
agree with, or feel is safe. You have the right to appeal (ask for
another review) this decision. By law, the hospital must let you
know how to appeal and explain what will happen. Make sure the
hospital provides you with contact information for the Beneficiary
and Family Centered Care-Quality Improvement Office (BFCC-
QIO) that reviews such appeals. You can find a list by state at
http://www.nextstepincare.org/Links_and_Resources/Federal/Me
dicare_Appeals/.

www.nextstepincare.org ©2014 United Hospital Fund 3

139
 Home Care

Next Step: Getting Ready to Go Home

There is a lot to think about as you get ready for your family
member’s transition from hospital to home. Here are some
important issues to keep in mind:

Equipment and Supplies

Make sure to get all the needed equipment and supplies. Find
out what the hospital or home care agency provides and what
you must get. Here are some good questions to ask:
 Does my family member need a hospital bed, shower chair,
commode, oxygen supply, or other equipment? If so, where do
I get these items?
 What supplies do I need? This may be diapers, disposable
gloves, and skin care items.
 Do I get these from the hospital or a home care agency, or will I
need to buy them?
 Where can I find these supplies if I have to buy them?
 Will my family member’s insurance pay for them?

Home Space

Your family member’s home should be comfortable and safe,

and a good place for care. Ask the hospital team if you need to
do anything special to get ready. This might be to:
 Make room for a hospital bed or other large equipment.
 Move out items that can cause falls such as area rugs and
electric cords.
 Arrange a safe place to store medications.
 Create a place to sit near your family member.
 Have a place for important information, such as a bulletin
board, notebook, or a drawer

www.nextstepincare.org ©2014 United Hospital Fund 4

140
 Home Care

Health Care Tasks

You will likely do certain tasks as part of giving care. It is important

that you know how to do these safely. Try to learn as much as
you can while your family member is still in the hospital. You
can do this by watching hospital staff as they do these tasks and
asking them to watch as you try these tasks yourself.
Sometimes, hospital staff will not teach these tasks until the day
of discharge. This may not be a good time to learn if you feel
rushed or overwhelmed. Learn what you can, and ask who to call
if you have questions at home.
You might be told to call someone from the hospital, a home care
nurse, or other health care professional.
Speak up if you are afraid of doing certain tasks (such as wound
care) or cannot help with personal hygiene (like helping your
family member take a shower or go to the bathroom). Some
caregivers are okay with changing their family member’s diapers
while others feel very uncomfortable about doing this task. Think
about your own feelings as well as your family member’s. The
hospital team needs to know what tasks you can and cannot
do so they can plan for any needed help.

Special Foods

Ask the hospital team if there are certain foods your family
member can or cannot eat. This might include specific foods
such as milk or meat, or general types of food, such as very soft
food or liquids. If your family member needs any special foods, try
to buy them before discharge when it is easier to shop.

www.nextstepincare.org ©2014 United Hospital Fund 5

141
 Home Care

Medication

One of your jobs as a caregiver may be “medication

management” — making sure your family member takes the
right medication, at the right time, and in the right amount.
Here are some questions to ask that can help you do this job well:
 What new medications will my family member take?
 For all new medications, how long should he or she take them?
 Should this medication be taken with meals? At certain times
each day?
 Does the medication have any side effects?
 Can it be taken with other medications?
 Is this new medication listed in the Medication Management
Form, along with my family member’s other prescriptions,
over-the-counter medications, vitamins, and herbal
supplements?
 Do I get this medication from my pharmacy or the hospital?
 Will my family member’s insurance pay for these medications?
If not, are there other medications that work just as well and
cost less?

A Medication Management Guide and a form that can help you

organize your family member’s medication information, are
available on www.nextstepincare.org.

www.nextstepincare.org ©2014 United Hospital Fund 6

142
 Home Care

At Home: Giving Care

Know Who to Call and What to Do
You may have a lot of questions during the first few days at home.
Make sure you have phone numbers for people on the
hospital team, as well as any home care agency involved with
your family member’s care.
Make sure you know what to do for your family member’s care.
This includes knowing:
 Are there any symptoms that you must report right away, such
as fever, intense pain, or shortness of breath? If you notice
these symptoms, who do you call, and what should you do?
 Are there limits or restrictions on what your family member
can do? For example, your family member might not be able to
take a bath, lift heavy things, or walk up or down stairs.
 Is it safe to leave your family member alone? If not, what
should you do, for instance, when you need to go work?

Arrange for Follow-Up Care


You should find out about
Your family member may have one or more new health care
professionals once he or she is home. Even if no new health care
local resources. Many professionals are involved, your family member should have a
communities have follow-up visit with his or her doctor.
resources that can help
Here are some questions you can ask about follow-up care before
you and your family
leaving the hospital:
member, such as:
Help with transportation  What health professionals does my family member need to
or financial assistance, see?
and friendly volunteer
 Who should I call to make these appointments?
visits for your family
member,  Where will the appointments be? In an office, at home, or
counseling, support somewhere else?
groups, and respite care
 What should I do if I cannot get an appointment within a
(time away from
certain time?
caregiving) for family
caregivers.  How will my family member’s doctor learn what happened in
the hospital?

www.nextstepincare.org ©2014 United Hospital Fund 7

143
 Home Care


Being a caregiver is a big
job whether your family Plan for Routine Care
member is in the hospital, Even though all days are not the same, it helps when you have a
getting ready to go home, plan for routine care. This means knowing what tasks are done
or already at home. You each day and who will do them. If you are working with a home
need to take care of care agency, find out what jobs they and you will each need to do.
yourself, not just your
family member. This Paying for Care
means paying attention to
your feelings as well as You will have to deal with your family member’s hospital bills at
physical health. It also some point. Make sure to read these bills closely, and make
means taking time for sure that your family member received all the listed services.
yourself—even for just a Let the hospital or insurance company know if there are any
short while each day. problems.
Dealing with these bills can be difficult, and some caregivers ask
other family members to help. You may also have to deal with
other financial and insurance issues. Each time you speak with a
representative about these issues, write down who you spoke
with, and what you discussed. Sometimes you may hear that
Medicare or other insurance will not pay for a needed service. If
so, check the facts for yourself.
Here are some ways:
 Talk with the hospital team who planned your family
member’s discharge. They may be able to arrange ways of
paying for home care services.
 Call your State Health Insurance Assistance Program (SHIP).
You can find contact information for SHIP programs in other
states by going to the Medicare website at
www.medicare.gov/contacts/static/allStateContacts.asp
 If your family member has Medicare, you can contact the
Medicare Rights Center. You can call 800-333-4114 and ask to
speak to with a Medicare specialist. You can also check online
at www.medicarerights.org

www.nextstepincare.org ©2014 United Hospital Fund 8

144
Discharge Preparation Checklist Patient:

Before I leave the care facility, the following tasks should be completed:

!
I have been involved in decisions I understand what my My family or someone close
about what will take place after I medications are, how to obtain to me knows that I am coming
leave the facility. them and how to take them. home, is available to care for me
and knows what I will need once
I leave the facility.
My doctor or nurse has answered I understand the potential
my most important questions side effects of my medications
prior to leaving the facility. and whom I should call if I If I am going directly home,
experience them. I have scheduled a follow-up
appointment with my doctor,
I understand where I am going
and I have transportation to
after I leave this facility and what I understand what symptoms I
this appointment.
will happen to me once I arrive. need to watch out for and whom
to call should I notice them.
I have what I need at home
I have the name and phone
(medication, equipment,
number of a person I should I understand how to keep
home modifications).
contact if a problem arises my health problems from
during my transfer. becoming worse.

This tool was developed by Eric Coleman, MD, MPH, UCHSC, HCPR, with funding from the John A. Hartford Foundation and the Robert Wood Johnson Foundation.

145
 Patient: Date:
MY CARE TRANSITION PLAN I was in the hospital because:
Dates of hospitalization:

If I have the following problems... I should:

!

My next appointments: Things to talk to my doctor about at my next visit:

With

Address

Date/Time Phone

With

Address

Date/Time Phone

With

Address

Date/Time Phone

Important contact information:

My primary doctor My care coordinator/care manager

Name Phone Name Phone

My hospital doctor My visiting nurse or home health care provider

Name Phone Name Phone

My hospital nurse My pharmacy

Name Phone Name Phone

146
 Patient: Last updated:
MY CARE TRANSITION PLAN
Note what the Include any special Use the grid below to write down
medication does. instructions for the the amount you take in each time
For example: lowers medication, such as slot (for example, 1 in the morning
blood pressure or take with food or and 1 1⁄2 at bedtime).
for pain relief stop taking on 1/14

My daily medications list: Amount to take and when to take

Name What it does How to take Morning Noon Evening Bedtime

As-needed medications:
Name What it does How to take How much and how often

147
Harrison Medical Center Teach Back Education Tool

Washington State Hospital Association - Partnership for Patients, 3/7/2017

148
 Follow-up Call by Clinical Staff

Hello Mr. /Ms. _____________ I am (caller’s name), a (title) from (name of facility). I am calling to see how you
are doing after your discharge and if there is anything I can do to help you. We will also review your medications
during this call. Can you bring all of your medications including non-prescription medicines and herbal
supplements to the telephone, please?
HEALTH STATUS:
1. Before you left the hospital, your main medical problem during your hospital stay was explained to you.
Can you explain to me your main problem or diagnosis?
a. Yes – Confirm the patient’s knowledge of the discharge diagnosis.
b. No – Use this opportunity to provide patient education about the discharge diagnosis.
2. Do you have any questions for me about your diagnosis?
a. Yes – Explain again.
b. No – Continue.
3. Since you left the hospital, do you feel your main problem has improved, worsened or not changed? What
does your family or caregiver think?
a. Worsened – Refer to an appropriate provider.
b. Improved/No change – Continue.
4. Have you experienced any new medical problems since you left the hospital?
a. Yes – Ask what has happened?
b. No – Continue.
WARNING SIGNS:
• What did the medical care team tell you to watch out for to make sure you are okay? Review specific
symptoms to watch out for and things to do for this diagnosis e.g. weigh self, blood sugar, blood pressure,
peak flow chart, etc.
• Do you have any questions about what to do if a problem arises?
FOLLOW-UP:
1. Can you please tell me what appointments are scheduled? Who is it with? If it is a lab/test, what is
it for? When is it? Are you going to be able to make it to your appointment?
a. Yes – Continue.
b. No – Help with the issues or get appointment rescheduled.
Note: If there is no appointment scheduled already, set up an appointment based on the discharging provider’s
request and according to the triage grid.
2. Please remember to bring all your medications, including non-prescription medicines and herbal
supplements, with you to your visit.
MEDICATIONS:____________________________________________________________
What questions do you, your family, or caregiver have regarding your medications?
EDUCATION PROVIDED:________ ________________________________________________
Do you have any other questions for me?
ADDITIONAL ACTIONS TAKEN_________________________________________________
Adapted from Project RED

Washington State Hospital Association - Partnership for Patients, 3/7/2017

149
 Tool 10.2: Follow-up Call by Non-Clinical Staff

Hello Mr. /Ms. _____________ I am (caller’s name), a (title) from (name of facility). I am calling to see how you
are doing after your discharge and if there is anything I can do to help you.
FOLLOW-UP:
1. Can you please tell me what appointments are scheduled? Who is it with? If it is a lab/test, what is it for?
When is it? Are you going to be able to make it to your appointment?
a. Yes – Continue.
b. No – Help with the issues or get appointment rescheduled.
Note: If there is no appointment scheduled already, set up an appointment based on the discharging provider’s
request and according to the triage grid.

2. Please remember to bring all your medications, including non-prescription medicines and herbal
supplements, with you to your visit.
WARNING SIGNS:
• What did the medical team tell you to watch out for to make sure you are okay?
• Do you have any questions about what to do if a problem arises?
a. Yes – Continue.
b. No/Have questions – Refer to a clinician.
HEALTH CARE STATUS:
• Before you left the hospital, someone spoke to you about your main problem during your hospital stay.
Can you explain to me your main problem or diagnosis?
a. Yes – Continue.
b. No – Refer to a clinician.
• Since you left the hospital, do you feel your main problem has improved, worsened or not changed? What
does your family or caregiver think?
a. Worsened – Refer to a clinician.
b. Improved/No change – Continue.
Have any new medical problems occurred since you left the hospital?
a. Yes – What has happened? Refer to a clinician.
b. No – Continue.
MEDICATIONS:____________________________________________________________________
What questions do you/your family or caregiver have regarding your medications?
(Refer to a clinician if there are questions)
EDUCATION PROVIDED:_________________________________________________________
Do you have any other questions that I can forward to the clinical team?
ADDITIONAL ACTIONS TAKEN: ___________________________________________________
Adapted from Project RED

Washington State Hospital Association - Partnership for Patients, 3/7/2017

150
 Behavioral Health Treatment and Resources
How do people with Medicaid coverage access mental health and/or substance use disorder
treatment?

Washington Medicaid enrollees have access to two types of benefits:

1. Through Apple Health: All clients eligible for a Fully Integrated Managed Care (FIMC) or
Behavioral Health Services Only (BHSO) are eligible for Behavioral Health services. This includes
Mental Health and Substance Use Disorder (SUD) benefits and services. These programs are
managed by the Health Care Authority (HCA) through contracts with the Managed Care
Organizations (MCO). To access this service through Apple Health plans:
o If your client is already enrolled in an Apple Health managed care plan, they may contact
their plan directly.
o If your client is not enrolled in an Apple Health managed care plan, or they don’t know how
to reach their plan, they can call the HCA at 1-800-562-3022 for help with finding a mental
health provider that accepts Medicaid insurance. Please see our next section on “How do
American Indians and Alaska Natives (AI/AN) access Medicaid-covered substance use
disorder treatment services?”

2. Through BH-ASOs: This benefit is for those who need additional mental health and
substance use disorder services not covered by the Apple Health plan, See page three for a
complete list of these services. To access these services, clients may:
o Contact the BH-ASO for their region directly.
o Contact a BH-ASO contracted treatment agency directly.
o Contact the 24-hour, free and confidential Washington Recovery Help Line at 1-866-789-
1511 (TTY 1-206-461-3219) or visit www.waRecoveryHelpLine.org. They will be referred
to a BH-ASO that will connect them with a provider.

How do American Indians and Alaska Natives (AI/AN) access Medicaid-covered substance use
disorder treatment services?

• The State will assign to the Fee-For-Service (FFS) program for SUD services all individuals
who self-identify as AI/AN when they:
o Apply or recertify for Medicaid; or
o Submit a subsequent change in the HealthPlanFinder website; or
o Contact the HCA Medical Customer Service Center.

• Medicaid-enrolled AI/ANs will be able to request Substance Use Disorder (SUD) treatment
services from any SUD provider enrolled with Medicaid as a FFS provider.

Rev 11.20.2023
151
 • In the FFS program, these services do not require BH-ASO or State authorization. SUD
providers must continue to meet all requirements of their state-issued license or certification in
order to maintain their status as a Medicaid FFS provider.

• BH-ASO fact sheet: https://www.hca.wa.gov/assets/program/bhaso-fact-sheet.pdf

• BH-ASO map: https://www.hca.wa.gov/assets/free-or-low-cost/19-0040-bh-aso-map.pdf
• Link to HCA website on BH-ASO: https://www.hca.wa.gov/health-care-services-supports/apple-
health-medicaid-coverage/apple-health-managed-care
• Link to County Crisis Line phone numbers: https://www.hca.wa.gov/health-care-services-
supports/behavioral-health-recovery/mental-health-crisis-lines
• 19-0036 Service Area Map. https://www.hca.wa.gov/assets/free-or-low-
cost/service_area_map.pdf
• Welcome to Washington Apple Health BHSO booklet: www.hca.wa.gov/assets/free-or-low-
cost/19-049.pdf

MCO Contacts:

Rev 11.20.2023
152
Behavioral health administrative service
organization (BH-ASO) fact sheet
What is a BH-ASO?
The Health Care Authority (HCA) is transforming health care by focusing on the whole person, and ensuring care is
coordinated and delivered where and when a person needs it. By January 2020, all regions of the state will transition to an
integrated system for physical health, mental health, and substance use disorder (SUD) services in the Washington Apple
Health (Medicaid) program. This is called integrated managed care (IMC).
Under the IMC program, most services for Apple Health clients are provided through managed care organizations. However,
some services in the community, such as services for individuals experiencing a mental health crisis, must be available to all
individuals, regardless of their insurance status or income level.
For this reason, HCA will contract with a BH-ASO to provide these services within a region.

What services will the BH-ASO provide?

Certain services must be available to anyone, regardless of their insurance status or income level. The following services may
be provided by the BH-ASO to anyone in the region who is experiencing a mental health or SUD crisis:
• A 24/7/365 regional crisis hotline for mental health and SUD crises.
• Mental health crisis services, including the dispatch of mobile crisis outreach teams, staffed by mental health
professionals and certified peer counselors.
• Short-term SUD crisis services for people intoxicated or incapacitated in public.
• Application of mental health and SUD involuntary commitment statutes, available 24/7/365, to conduct Involuntary
Treatment Act assessments and file detention petition.

What services will the BH-ASO provide to people who are low income, uninsured,
and/or not eligible for Apple Health?
The BH-ASO may provide certain mental health services and SUD services (referred to as behavioral health services) to people
not enrolled in or eligible for Apple Health. For some services, such as services funded through the federal Substance Abuse
Block Grant or Mental Health Block Grant, individuals may need to meet other priority population requirements to be
considered eligible.
The BH-ASO may provide the following services to individuals who are not eligible for Apple Health:
• Mental health evaluation and treatment services for individuals involuntarily detained or who agree to a voluntary
commitment.
• Residential SUD treatment services for individuals involuntarily detained as described in state law.
• Outpatient behavioral treatment services, in accordance with a Less Restrictive Alternative court order.
• Within available resources, the BH-ASO may provide non-crisis behavioral health services, such as outpatient SUD
and/or mental health services, or residential SUD and/or mental health services to low-income individuals not eligible
for Apple Health and who meet other eligibility criteria.

153
What other administrative functions will the BH-ASO manage in the region?
Within the region, the BH-ASO may:
• Provide a behavioral health ombudsman to assist individuals with grievances and appeals.
• Manage the block grants based on locally approved block grant plans.
• Manage Criminal Justice Treatment Account funds and Juvenile Drug Court funds.
• Oversee committees formerly led by the regional behavioral health organization, such as the Behavioral Health
Advisory Board, Wraparound with Intensive Services, Children’s Long-term Inpatient Program, and Family Youth
System Partner Round Table.

Visit the HCA website to learn more about the integration of physical and behavioral health.

Updated November 2019 2

154
 OLDER AMERICANS BEHAVIORAL HEALTH
Issue Brief 6: Depression and Anxiety:
Screening and Intervention
Depression in Older Adults
Depression is not a normal part of aging. It is a medical problem that affects
many older adults and can often be successfully treated. Symptoms of
depression include: depressed mood, loss of interest or pleasure in activities,
disturbed sleep, weight loss or gain, lack of energy, feelings of worthlessness
or extreme guilt, difficulties with concentration or decision making,
noticeable restlessness or slow movement, and frequent thoughts of death or
suicide or an attempt of suicide.1
Up to 5% of older adults in the community meet diagnostic criteria for major
depression, and up to 15% have clinically significant depressive symptoms
that impact their functioning (otherwise known as sub-syndromal depression
or minor depression).2 However, the prevalence of depression is substantially
Introduction and Overview higher in older adults with medical illnesses, and in those who receive
services from aging service providers. For instance, a recent study found
that more than one-quarter (27%) of older adults assessed by aging service
The Substance Abuse and Mental Health Services
providers met criteria for having current major depression and nearly one-
Administration (SAMHSA) and Administration
third (31%) had clinically significant depressive symptoms.3 Depression is
on Aging (AoA) recognize the value of strong
often under-recognized and under-treated in older adults.
partnerships for addressing behavioral health issues
among older adults. This Issue Brief is part of a Depression can impair an older adult’s ability to function and enjoy life and
larger collaboration between SAMHSA and AoA to can contribute to poor health outcomes and high health care costs. Compared
support the planning and coordination of aging and to older adults without depression, those with depression often need greater
behavioral health services for older adults in states and assistance with self care and daily living activities and often recover more
communities. Through this collaboration, SAMHSA slowly from physical disorders. Without appropriate treatment, symptoms of
and AoA have developed Issue Briefs and archived depression can limit an older adult’s ability to achieve successful aging.4
webinars in the areas of suicide, anxiety, depression, Depression in older adults may be linked to several important risk factors.
and alcohol and prescription drug use and misuse These include, among others4,5:
among older adults, and are partnering to get these
resources into the hands of aging and behavioral • Medical illness (particularly • Alcohol or prescription
health professionals. chronic health conditions medication misuse or abuse,
associated with disability/decline), • Prior depressive episode, or
This Issue Brief is intended to help health care and
• Perceived (self-reported) poor family history of depression,
social service organizations develop strategies to serve health, disability, or chronic pain, • Extended or long-standing
older adults with depression and anxiety, by providing:
• Progressive/disabling sensory bereavement,
• Information on the prevalence, risk factors, and loss (e.g., macular degeneration), • Stressful life events (e.g.,
impact of depression and anxiety in older adults; • History of recurrent falls, financial difficulties, new illness/
• Recommendations on screening, assessment, and • Sleep disturbances, disability, change in living
early intervention and treatment strategies; and • Cognitive impairment or dementia, situation, retirement or job loss,
and interpersonal conflict), and
• Recommendations and Resources to help aging • Medication side effects (e.g.,
benzodiazepines, narcotics, beta • Dissatisfaction with one’s social
services, behavioral health, and primary care
blockers, corticosteroids, and network.
providers develop effective depression and anxiety
services for older adults. hormones),

155
1
 Anxiety in Older Adults
Like depression, excessive anxiety that causes distress or that • Chronic medical conditions (especially chronic obstructive
interferes with daily activities is not a normal part of aging. pulmonary disease (COPD), cardiovascular disease including
Anxiety disorders cause nervousness, fear, apprehension, and arrhythmias and angina, thyroid disease, and diabetes),
worrying. They can worsen an older adult’s physical health, • Perceived (self-reported) poor health,
decrease their ability to perform daily activities, and decrease
• Sleep disturbance,
feelings of well-being.6
• Side effects of medications (e.g., steroids, antidepressants,
Three to 14% of older adults meet the diagnostic criteria for stimulants, bronchodilators/inhalers),
an anxiety disorder,6 however a greater percent of older adults
• Alcohol or prescription medication misuse or abuse,
have clinically significant symptoms of anxiety that impact their
functioning. For instance, a recent study found that more than • Physical limitations in daily activities,
one-quarter (27%) of aging service network care management • Stressful life events,
clients have clinically significant anxiety.7 The most common • Adverse events in childhood, and
anxiety disorders include specific phobias and generalized • Neuroticism or preoccupation with somatic (physical)
anxiety disorder. Social phobia, obsessive-compulsive disorder, symptoms.
panic disorder, and post-traumatic stress disorder (PTSD) are
less common.6 Like depression, anxiety disorders are often Older adults with mixed anxiety and depression often have
unrecognized and undertreated in older adults. The detection more severe symptoms of depression and anxiety, poorer social
and diagnosis of anxiety disorders in late life is complicated functioning, greater use of health care services, more physical
by medical comorbidity, cognitive decline, changes in life health symptoms (e.g., chest pain, headaches, sweating,
circumstances, and changes in the way that older adults report gastrointestinal problems), more thoughts of completing
anxiety symptoms.6 suicide, and a slower response to treatment. Older adults with
Anxiety in older adults may be linked to several important risk depression and anxiety are more likely to stay in treatment if
factors. These include, among others: 6 they are seen frequently and are told that they should call with
any concerns related to treatment.4

Assessing Symptoms of Depression

and Anxiety
Several tools can help aging service, behavioral health,
and primary care providers identify older adults who have
symptoms of depression and anxiety. These tools can be used
to screen for symptoms, assess the severity of symptoms, and
monitor treatment progress. The following depression and
anxiety scales are available without charge, and have been
translated into several languages.
• Geriatric Depression Scale (GDS): A 15-item screening
measure for depression in older adults. (http://www.
stanford.edu/~yesavage/GDS.html).
• Patient Health Questionnaire (PHQ-9): A 9-item scale
that assesses DSM-IV depression criteria. (http://www.
phqscreeners.com). The first two questions of the PHQ-
9 are often referred to as the PHQ-2 and can be used
to identify the need for a more complete assessment of
depressive symptoms using the PHQ-9 or GDS.
• The Generalized Anxiety Disorder 7-item Scale (GAD-7):
A 7-item scale that assesses common anxiety156symptoms.
2
 EVIDENCE-BASED
DEPRESSION4,5 ANXIETY6
TREATMENT
Treating Symptoms of Depression Antidepressant medications Effective Effective

and Anxiety Cognitive behavioral therapy Effective Effective

Problem solving therapy Effective

Several treatments can reduce the symptoms of
depression and anxiety for most older people. These Interpersonal therapy Effective
treatments can be delivered by care providers from
different disciplines and in different settings. The
most common and effective treatments for depression older adults have participated in these programs.
and anxiety, based on scientific evidence, include Similarly, the IMPACT model of integrated physical
medications and psychotherapy. and behavioral health has been implemented in over
30 states. Estimates from 2007, suggested that over
Many communities have embedded effective depression
500 sites and 50,000 older adults have participated in
treatments into service models delivered within primary
IMPACT. To identify if these programs are available in
care or social service settings, or within the older
your community, visit the websites identified in the table
adult’s home. These programs often include meaningful
below or contact the program developers.
collaboration across different types of service providers
(e.g., aging service, behavioral health, and primary care If these evidence-based treatments or service delivery
providers). models are not available in your community, consider
whether you can implement them in your organization.
The PEARLS and Healthy IDEAS models of
Training manuals and implementation support are
community-based depression care management
available (see Resources: Treatment of Depression in
have been implemented in over 25 states. Estimates
Older Adults EBP KIT).
from 2012, suggested that over 114 sites and 30,000

PRIMARY ADDITIONAL
PROGRAM SETTING KEY COMPONENTS
COLLABORATIONS RESOURCES
IMPACT: Improving Primary Primary care, Collaborative care, care from a depression http://impact-uw.org
Mood, Promoting care Behavioral health care manager, consultation with a designated http://www.nrepp.samhsa.
Access to Collaborative psychiatrist, outcome measurement, gov/ViewIntervention.
Treatment and stepped care (with antidepressant aspx?id=105
medications and problem solving treatment).
PROSPECT: Prevention Primary Primary care, Recognition of depression and suicidal http://www.nrepp.samhsa.
of Suicide in Primary care Behavioral health thoughts by primary care practitioners, use gov/ViewIntervention.
Care Elderly of a treatment algorithm with antidepressant aspx?id=257
medication and interpersonal therapy, and
treatment management by depression care
managers.
PEARLS: Program to Home Primary care, Home Targets older adults with minor depression http://www.pearlsprogram.
Encourage Active, health, Social services, or dysthymia through 6-8 in-home sessions org
Rewarding Lives for and Aging services using problem-solving therapy and behavioral
Seniors activation.
Healthy IDEAS: Home Behavioral health, Screening and assessment, education for http://careforelders.org/
Identifying Depression, Social services, and clients and family caregivers, referral and default.aspx?menugroup=
Empowering Activities Aging services linkages to appropriate health professionals, healthyideas
for Seniors and behavioral activation.

157
3
 Lessons Learned
from the Field
Aging service, behavioral health, and primary care Key Actions for Behavioral Healthcare
providers and administrators can take important steps
Providers
to identify older adults with depression and anxiety,
and reduce symptoms of these disorders. General • Assess for co-occurring behavioral health conditions
(e.g., depression, anxiety, substance misuse or abuse,
recommendations across all settings include: cognitive impairment) and structure the older adult’s
• Identify gaps in services available for older adults with care to address these areas.
depression and anxiety, and identify the type of program • Assess the degree to which anxiety symptoms cause
that can be most useful in meeting your needs. distress or interfere with daily activities, even if the older
adult does not meet diagnostic criteria for an anxiety
• Seek implementation support from technical experts disorder.
or program developers.
• Increase the effectiveness of behavioral health services
• Actively involve older adults and their families by implementing evidence-based practices, tracking
or caregivers when implementing and sustaining a outcomes systematically, and taking steps to improve
new program to address depression or anxiety (e.g., treatment compliance.
marketing, advisory councils, etc.). • Tailor psychotherapy interventions to address
• Use standardized depression and anxiety scales as the cognitive, physical, and sensory needs of older
adults (e.g., providing between-session reminder
outcome measures to evaluate the effectiveness of telephone calls, repetition, weekly review of concepts,
program implementation and treatment. at-home assignments, and breaking tasks into smaller
• Learn how demographic characteristics and cultural components).
beliefs influence perceptions of depression and anxiety,
treatment access, treatment preferences, and desired Key Actions for Primary Healthcare
outcomes.
Providers
• Incorporate cultural awareness into the assessment and
• Implement routine, standard screening and follow-up
treatment of older adults. assessments for depression, anxiety, and suicidal ideation
(e.g., PHQ-9, GDS, GAD-7).
Key Actions for Aging Services Providers • Optimize treatment of chronic medical conditions,
• Train aging service providers (and laypersons) to pain, sleep problems, or other physical symptoms
identify warning signs and provide treatment or refer to that can decrease quality of life and increase risk for
services those older adults who are at-risk for depression, depression and anxiety.
anxiety, or suicide.
• Optimize diagnosis and treatment of late-life
• Introduce routine depression, anxiety, and suicide depression by using collaborative depression care
screening in the course of non-clinical activity management interventions.
(e.g., senior day care, senior transportation, senior
companions). • Adapt existing collaborative care models to include
management of late-life anxiety, and to include linkages
• Provide systematic outreach to assess and support between aging service, behavioral health and primary
high-risk older adults in improving life conditions, and care networks.
addressing issues and needs that can reduce stress.
• Focus services on reducing disability and enhancing
independent functioning.
• Increase provider awareness of substance abuse and
mental health problems in older adults.

158
4
Actions for Coordination, Integration,
and Financing of Services Resource Guide that reviews funding sources and
financing strategies that organizations used to sustain
Partnerships, coordination of care, and integration across behavioral health programs after grant funding ended.
service settings can help provide effective care for older Although financing case identification and appropriate
adults with depression or anxiety. treatment can be a challenge, there are several options for
• Build collaborative relationships with community, state, funding services:
and federal partners. • Many treatments for depression and anxiety can be
• Build collaborative relationships across aging, reimbursed through Medicare, Medicaid, and private
behavioral health, and primary care partners. Many insurance.
public and private funding sources support behavioral • Some non-billable services may be funded through
health services for older adults. The National Council private foundation support.
on Aging (NCOA), in partnership with SAMHSA, • Outreach and case identification can be performed by
developed Lessons Learned on Sustainability of Older well-trained volunteers (e.g., Gatekeepers8).
Adult Community Behavioral Health Services, available • Braided funding options incorporate funding from
on http://www.ncoa.org. The report features a Financial multiple funding streams.

Resources • National Council on Aging. (2012). Lessons Learned

on Sustainability of Older Adult Community Behavioral
• National Registry of Evidence-based Programs and Health Services. http://www.ncoa.org/improve-health/
Practices: http://www.nrepp.samhsa.gov center-for-healthy-aging/content-library/lessons-
• Center for Mental Health Services. (2011). Treatment of learned-on.html
depression in older adults evidence-based practices (EBP)
KIT. HHS Publication No. SMA-11-4631. Rockville,
MD: Substance Abuse and Mental Health Services
Administration. http://store.samhsa.gov/product/
Treatment-of-Depression-in-Older-Adults-Evidence-
Based-Practices-EBP-KIT/SMA11-4631CD-DVD

Works Cited
1 American Psychiatric Association. (1994). Diagnostic and 5 Fiske A, Wetherell JL, Gatz M. (2009). Depression in older adults.
Statistical Manual of Mental Disorders (DSM-IV) (Fourth Edition - Annual Review of Clinical Psychology. 5: 363-389.
Revised). Washington, D.C. 6 Wolitzky-Taylor KB, Castriotta N, et al., (2010). Anxiety
2 Hybels CF, Blazer DG. (2003). Epidemiology of late-life mental disorders in older adults: A comprehensive review. Depression and
disorders. Clinics in Geriatric Medicine, 19(4): 663-696. Anxiety. 27: 190-211.
3 Richardson TM, Friedman B, et al. (2012). Depression and its 7 Richardson TM, Simning A, et al. (2011). Anxiety and its
correlates among older adults accessing aging services. American correlates among older adults accessing aging services. International
Journal of Geriatric Psychiatry. 20(4): 346-354. Journal of Geriatric Psychiatry. 26(1), 31-38.
4 Center for Mental Health Services. (2011). Treatment of 8 Bartsch DA, Rodgers VK. (2009). Senior reach outcomes
depression in older adults evidence-based practices (EBP) KIT. HHS in comparison with the Spokane Gatekeeper program. Care
Publication No. SMA-11-4631. Rockville, MD: Substance Abuse Management Journal. 10(3): 82-88
and Mental Health Services Administration. http://store.samhsa.
gov/product/Treatment-of-Depression-in-Older-Adults-Evidence-
Based-Practices-EBP-KIT/SMA11-4631CD-DVD

2013 159
5
 HEALTH HOME
Goal Setting and Action Planning Worksheet
NAME DATE

Long Term Goal

Short Term Goal

Describe something you will do now to improve your health.

Describe what you will do

1. What you’ll do:
2. Where you’ll do it:
3. The number of times each day / week:
4. How long will you commit to doing this:
Possible barriers to your success:

Plan to overcome the barriers:

Conviction
How important is it for you to work on the goal you identified above? Check the box which best shows your response.
Not at all convinced 1 2 3 4 5 6 7 8 9 10 Totally convinced
Confidence
How confident are you that you will be successful in reaching the goal you identified above?
Check the box which best shows your response.
Not at all confident 1 2 3 4 5 6 7 8 9 10 Totally confident
Readiness
How ready are you to work on the goal you identified above? Check the box which best shows your response.
Not at all ready: 1 2 3 4 5 6 7 8 9 10 Totally ready

Plan for follow-up:

HEALTH HOME GOAL SETTING AND ACTION PLANNING WORKSHEET

DSHS 10-442 (REV. 02/2015)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

REASON FOR CLOSURE OF THE HAP REASON FOR TRANSFER OF THE HAP
Beneficiary Opted Out Move to a county that does not have Health Home services Client choice to change CCO or Lead Organization
Death No longer eligible Eligibility changed (change to/from FFS or MCO)
CLIENT INTRODUCTION

CLIENT’S LONG TERM GOAL DIAGNOSIS (PERTINENT TO HAP)

Initial / Annual HAP Required Screenings Four Month Update Required Screenings Eight Month Update Required Screenings
IF NOT COMPLETE,
SCREEN DATE SCORE / LEVEL IF NOT COMPLETE, EXPLAIN SCREEN DATE SCORE / LEVEL SCREEN DATE SCORE / LEVEL IF NOT COMPLETE, EXPLAIN
EXPLAIN
PAM / PAM / PAM /
CAM / CAM / CAM /
PPAM / PPAM / PPAM /
Katz ADL Katz ADL Katz ADL

PHQ-9 PHQ-9 PHQ-9

PSC-17 PSC-17 PSC-17

BMI BMI BMI

OPTIONAL SCREENING SCORES OPTIONAL SCREENING SCORES OPTIONAL SCREENING SCORES

SCREEN DATE SCORE SCREEN DATE SCORE SCREEN DATE SCORE

DAST DAST DAST

GAD-7 GAD-7 GAD-7

AUDIT AUDIT AUDIT

FALLS FALLS FALLS
RISK RISK RISK
FLACC FACES
PAIN FLACC FACES NUMERIC PAIN PAIN FLACC FACES NUMERIC
NUMERIC
ADDITIONAL COMMENTS ADDITIONAL COMMENTS ADDITIONAL COMMENTS

HEALTH ACTION PLAN (HAP) Page 1

DSHS 10-481 (REV. 09/2017)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

Initial / Annual HAP Four Month Update Eight Month Update

Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

HEALTH ACTION PLAN (HAP) Page 2

DSHS 10-481 (REV. 09/2017)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

Initial / Annual HAP Four Month Update Eight Month Update

Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

HEALTH ACTION PLAN (HAP) Page 3

DSHS 10-481 (REV. 09/2017)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

Initial / Annual HAP Four Month Update Eight Month Update

Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

HEALTH ACTION PLAN (HAP) Page 4

DSHS 10-481 (REV. 09/2017)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

Initial / Annual HAP Four Month Update Eight Month Update

Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

HEALTH ACTION PLAN (HAP) Page 5

DSHS 10-481 (REV. 09/2017)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

Initial / Annual HAP Four Month Update Eight Month Update

Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

HEALTH ACTION PLAN (HAP) Page 6

DSHS 10-481 (REV. 09/2017)
 CLIENT’S FIRST NAME CLIENT’S LAST NAME MALE FEMALE UNKNOWN OTHER DATE OF BIRTH PROVIDER ONE CLIENT ID
Health Action Plan
HEALTH HOME LEAD ORGANIZATION HH LEAD ORGANIZATION PHONE
(HAP)
DATE OF HAP: BEGIN END DATE OPTED IN CARE COORDINATION ORGANIZATION CARE COORDINATOR’S NAME CARE COORDINATOR’S PHONE

Initial / Annual HAP Four Month Update Eight Month Update

Short Term Goal: Short Term Goal: Short Term Goal:
Goal Start Date: Goal End Date: Goal Start Date: Goal End Date: Goal Start Date: Goal End Date:
Outcome: Outcome: Outcome:
Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change Completed No longer pertinent – life or health change
Revised Client request to discontinue Revised Client request to discontinue Revised Client request to discontinue
COMPLETION COMPLETION COMPLETION
START DATE ACTION STEPS START DATE ACTION STEPS START DATE ACTION STEPS
DATE DATE DATE

HEALTH ACTION PLAN (HAP) Page 7

DSHS 10-481 (REV. 09/2017)
 HEALTH HOME
Health Action Plan
Instructions
Complete the Health Action Plan (HAP) for each client upon assignment to the Health Home program. The HAP provides
documentation of the health plan developed by the Care Coordinator, the client, the family, the parent and/or their
caregiver. The HAP is established for one assignment year with three columns representing a four month time period.
Each time period ranges from 120 to 123 days depending on the number of days within the four months.
The HAP must be updated a minimum of once during each four month activity period. The form provides three columns
for entry of the initial or annual HAP, the four month update, and the eight month update. At the completion of a year a
new HAP is started on the anniversary date. Long term goals, short term goals and action steps may be revised, deleted
or carried over to the next HAP period.

The HAP is updated by the Care Coordinator to address:

a. Outcomes of monthly contacts;
b. Changes in the client’s condition;
c. Care transitions between settings;
d. Updated goals;
e. Resolution of goals or action steps; or
f. When a client opts-out, dies or is no longer eligible for the program.
The following are documented in the client’s file or medical record: the client narrative, telephone calls, face-to-face visits,
collateral contacts, consultations, referrals, interventions, visits to providers, etc.
HAP FORM FIELDS FOR COMPLETION
Client’s First Name: Enter the first name of the client.
Client’s Last Name: Enter the last name of the client.
Gender: Check the appropriate box. Check “unknown” only if the gender of the client is unknown. Check other if the
client does not identify as either male or female, otherwise use male or female according to the client’s self-identification.

DSHS 10-481 (REV. 09/2017) INSTRUCTIONS PAGE 1 OF 3

Date of Birth: Enter the client’s date of birth.
ProviderOne Client ID: Enter the ProviderOne client identification number (9 digits followed by WA).
Health Home Lead Organization: Enter the name of the Lead Organization.
HH Lead Organization Telephone Number: Enter the number the client calls to talk with a Lead Organization client
representative.
Care Coordination Organization: Enter the name of the Care Coordination Organization (CCO).
Care Coordinator’s Name and Telephone Number: Enter the name of the Care Coordinator and their contact number.
Begin Date of HAP: Enter the date the Care Coordinator initiates the HAP. The HAP Begin Date and Opt-in Date are
the same. This date establishes the first date of the 12-month cycle for the first and subsequent 12-month cycles.
End Date of HAP: Enter the End Date when the Eight Month Update activity period ends. If the client leaves the
program before the end of the 12 month cycle (e.g., is no longer eligible) enter the date the client leaves the program. Do
not enter an end date if the client remains enrolled and moves or changes their Lead Organization or CCO.
Date Opted In: Enter the date the client agrees to participate by signing the Information Sharing Consent HCA 22-852
form. This date becomes the client’s anniversary date. It triggers the start of a new HAP for the next HAP reporting year.

Reason for Closure of the HAP: If applicable check the reason for closing the HAP (client opted out, no longer eligible,
or death). Enter an end date for the HAP.
Reason for Transfer of the HAP: If applicable check the reason for transferring the HAP (client choice to change CCO
or Lead Organization, or eligibility changed). Do not enter an end date as the HAP is still in effect during the transfer.
Client Introduction: Enter a brief introductory statement about the client. The introductory statement may include client
preferences and demographics (e.g. call in the afternoon, monolingual Spanish, call caregiver) or any other significant
information (e.g. the client’s living arrangement).
Client’s Long Term Goal: Enter the client’s person-centered long term goal. What would they like to happen as a result
of their care? What would they like be able to do that they can’t currently do? What is the most important thing they want
to achieve related to their chronic disease? For example, client states, “I want to feel better”, “I want to be able to travel to
Florida for a family reunion next year” or “I want to see my grandchildren grow up.” Connect the long term goal with the
Short Term Goal(s).
Diagnosis (Pertinent to the HAP): Enter the diagnoses being addressed by the client and Care Coordinator. This list
should only include the diagnoses being addressed by the HAP and may not reflect all of the client’s diagnoses and health
care needs. The list of diagnoses may need to be prioritized by the Care Coordinator and client for planned interventions.
HAP Required Screenings: Administer and report these mandatory screenings within each of the three HAP activity
periods (Initial/Annual, Four Month Update, and Eight Month Update). For example: if the begin date is February 1st,
administer the screenings in the Initial / Annual period between February 1st and May 31st, then again in the Four Month
Update period between June 1st and September 30th,etc. If the client, their caregiver, or parent is unable or declines to
complete a required screening enter the date the assessment was offered and provide an explanation in the “if not
complete / explain” field. Do not enter zero for the score. If a screening was completed enter the date, the score and
activation level if indicated.
Patient Activation Measure: A Patient Activation Measure® (PAM), Caregiver Activation Measure® (CAM), or Parent
Patient Activation Measure® (PPAM) must be entered for the client. The client’s age determines if a PAM, CAM, or
PPAM must be administered.
a. The PAM is required if the client is 18 years of age and over and a CAM has not been submitted. The PAM is not
used for clients under 18 years of age.
DSHS 10-481 (REV. 09/2017) INSTRUCTIONS PAGE 2 OF 3
b. The CAM is required if a PAM has not been submitted. It is optional if a PAM has been submitted. The CAM is not
used if the client is less than 18 years of age.
c. The PPAM is required if the client is less than 18 years of age.
Score: Enter the activation score. The value range is 0.0 to 100.0.
Level: Enter the PAM, CAM, or PPAM activation level. The value range is Level 1 to Level 4.
Katz Index of Independence in Activities of Daily Living: Enter the total number of points. The value range is 0 to 6.
The Katz ADL screening is not administered to clients under the age of 18 and no value is accepted.
PHQ-9 (Patient Health Questionnaire - Depression Screening): Enter the client’s PHQ-9 score. This is required for
clients 18 years of age and older. The value range is 0 to 27. Values for clients under the age of 18 will not be accepted.
PSC-17 (Pediatric Symptoms Checklist – 17): Enter the client’s PSC-17 score. This is required for clients, ages 4
through 17 years of age. The value range is 0 to 34.
Body Mass Index (BMI): Enter the client’s actual BMI. The value range is 0.0 to 125.9.
a. Use the Adult BMI chart for clients 20 years of age and older.
b. Use the Children and Teens BMI chart for children 2-19 years of age.
c. The BMI is neither used nor required for children less than two years of age (no value is accepted).
Optional Screenings: Optional screenings should be administered when applicable to identify possible issues, gaps in
care or when they relate to a client’s condition/s or goals stated within the HAP. Enter the date the screening was
completed and the score. Optional screenings may include:
a. DAST = Drug Abuse Screening Test: Enter the score. The value range is 0 to 10.
b. GAD-7 = Generalized Anxiety Disorder 7 item scale: Enter the score. The value range is 0 to 21.
c. AUDIT = Alcohol Use Disorders Identification Test (age 14 and older): Enter the score. The value range is 0 to 40.
d. Falls Risk = My Falls-Free Plan: Each “yes” response is equal to one point. Enter the score. The value range is 0 to
11.
e. Pain Scales: Enter the score and check the type of scale used (FLACC, Faces, or Numeric). The value range is 0 to
10.
Comments: Enter any comments or notes that relate to any of the fields above. For example, information shared by a
caregiver or parent.
Short Term Goal: Enter the client identified goal(s). Goals should be specific, measurable, attainable, relevant, and
time-based and must be mutually agreed upon. For example: “client wants to cut back on smoking over the next three
months or by the end of the year”, “client wants to understand how to use her blood pressure medication by the end of
January” or “client wants to be able to communicate with their physician and address questions and concerns at the next
medical appointment.”
Goal Start Date: Enter the date the client chooses to begin working toward the stated short term goal.
Goal End Date: Enter the date a goal is achieved, if a client chooses to end a goal, or there is no further need for the
goal.
Outcome: Check the applicable reason (completed, revised, no longer pertinent-life or health change, or client request to
discontinue). Goals that will continue from one activity period to another should be copied and continued with
modifications as needed for specific action steps.
Action Steps: Enter the Care Coordinator and client identified action steps the client, the parent, the family, the Care
Coordinator, their personal care worker or other caregivers, or health care providers plan to take to achieve the client’s
Short Term Goal(s). These action steps should be established mutually with the client recognizing the client’s abilities
and readiness for change and coaching. For example, “the Care Coordinators will review the ‘Your Guide to Lowering
Blood Pressure’ brochure with the client to help her understand her medications,” “the personal care worker will remind
the client to track her blood pressure daily.”
Start Date and Completion Date: Enter the start and completion dates for the action steps.

DSHS 10-481 (REV. 09/2017) INSTRUCTIONS PAGE 3 OF 3

Please contact your Lead
Organization for access to
the Patient Activation
Measure
Please contact your Lead
Organization for access
to the Caregiver
Activation Measure
Please contact your Lead
Organization for access
to the Parent Patient
Activation Measure
 Date
Pediatric Symptom Checklist
(PSC–17)
Name of Person Completing this Form Child’s Name Child’s Date of Birth
First Name Last Name First Name Last Name

Please check the box under the heading that best

describes your child or you. For Office Use
Only
(0) Never (1) Sometimes (2) Often

1. Feels sad, unhappy

2. Feels hopeless

3. Is down on self
Internalizing
4. Worries a lot Total
5. Seems to be having less fun

6. Fidgety, unable to sit still

7. Daydreams too much

8. Distracted easily
Attention
9. Has trouble concentrating Total
10. Acts as if driven by a motor

11. Fights with other children

12. Does not listen to rules

13. Does not understand other people’s feelings

14. Teases others

15. Blames others for his/her troubles

Externalizing
16. Refuses to share Total
17. Takes things that do not belong to him/her

Total Score

A score of 15 or higher may indicate the need for an assessment by a qualified medical or mental health professional.

PSC-17
DSHS 10-509 (08/2014)
 Instructions for Scoring the Pediatric Symptom Checklist - 17 (PSC-17)

What is the PSC–17?

The Pediatric Symptom Checklist (PSC) is brief screening questionnaire that is used to improve the recognition and
treatment of psychosocial problems in children ages 4 to 17 years. It is used in place of the PHQ-9 for Health Home
beneficiaries within this age group. Health Home beneficiaries ages 18 years and older are screened for psychosocial
issues using the Patient Health Questionnaire - 9 (PHQ-9).
What is the purpose for administering the PSC-17?
The PSC-17 should not be considered a diagnostic tool. Its purpose is to alert parents and guardians of potential
behavioral issues and encourage them to pursue further evaluation by a qualified medical or mental health professional.
Review of the scoring of the PSC-17 can provide an opportunity for Care Coordinators, family members or guardians,
caregivers, and the child to discuss development of the Health Action Plan (HAP) with goals and actions steps developed
to address some of the moods and behaviors the child may be exhibiting.
Is consent needed to administer or release the PSC-17?
Consent is not required by the biological, adoptive, or foster parent for children ages 13 years and older to self-administer
the PSC-17. Written consent is required by the parent or representative to release the questionnaire results for children
under the age of 13 years. Children ages 13 years and older must provide written consent to release the results of the
questionnaire.
Who completes the PSC-17?
The checklist is completed by the biological, adoptive, or foster parent, or guardian on behalf of the child. Children ages
13 or older may complete the questionnaire. The person who completes the questionnaire should check the box that best
describes the frequency of current moods or behaviors listed on the form.
What is the scoring for the PSC-17?
The values for scoring the 17 responses are: Never = 0 (zero) points Sometimes = 1 point Often = 2 points
The Care Coordinator tallies the score and enters the date and total score on the HAP. If a question is unanswered or left
blank, it is scored as a 0 (zero). Four or more responses left blank invalidate the questionnaire and the total score is not
entered on the HAP. If the family member or guardian is unable or declines to complete the questionnaire or the
questionnaire is invalidated, leave the score blank (do not enter a zero for the score) and note the reason that the
questionnaire was not completed or invalidated on Page 1 of the HAP.
How is the PSC-17 interpreted?
A total score of 15 or more points may indicate the need for a referral to a qualified medical or mental health professional.
The responses and score should be reviewed and discussed with the person who completes the questionnaire. With
proper written consent the results of the questionnaire may be released to other mental and/or medical healthcare
providers. The PSC-17 contains subscales for internalizing behavior, externalizing behavior, and attention. These
subscale scores are not recorded on the HAP but may be reviewed with the person completing the questionnaire.
Where can I find further information about the PSC-17?
For further information about the PSC, visit the Massachusetts General Hospital website at:
http://www.massgeneral.org/psychiatry/services/psc_home.aspx

PSC-17
DSHS 10-509 (08/2014) INSTRUCTIONS
 Health Home Participation Authorization
and Information Sharing Consent
1 Participation Authorization

I, , agree to participate in the Health Home program with

Print name of beneficiary Print name of Health Home Lead

Signature of beneficiary or beneficiary’s legal representative Date

2 Information Sharing Consent

Your health information is private and cannot be given to other people unless you agree or applicable Washington State or
federal laws allow the information to be shared. The providers/partners that can get and see your health information must obey
all these laws. This is true if your health information is on a computer system or on paper. In addition to laws that apply to all
types of health information, specific laws provide greater protection of information related to sexually transmitted diseases, mental
health treatment, and substance use disorder.

I agree that my Health Home can obtain all of my health information from the providers/partners listed on this form to
coordinate my care. I also agree that the Health Home and the providers/partners listed on this form may share my health
information with each other, and other providers/partners involved in managing my care. I understand this form takes the place
of any other Health Home Participation Authorization and Information Sharing Consent forms I may have signed before. I can
change my mind and take back my consent at any time by signing a Health Home Participation-Opt-Out/Decline Services
form and giving it to my Health Home.

PLEASE NOTE: If your health records include any of the following information, you must also complete this section to
include these records.
I give my permission to disclose information about (please put initials next to all that apply):
Mental health HIV/AIDS and STD test results, diagnosis, or treatment
Note: To give consent for the release of confidential alcohol or drug treatment information you must complete a separate Release of
Information (ROI) for Substance Use Disorder (SUD) Services form.
Please initial the appropriate choice below.
This consent is valid: as long as my Health Home needs my records for this program; or
until
date or event

I may revoke or withdraw this consent at any time in writing, but that will not affect any information already shared. A
copy of this form provides my permission to share records.

Print name of beneficiary Beneficiary’s date of birth

Signature of beneficiary or beneficiary’s legal representative Date

Print name of legal represenative (if applicable) Relationship of legal representative to beneficiary
List your providers/partners on page two.

HCA 22-852 (1/22)

Print name of Health Home beneficiary

List the name of participating Beneficiary gives consent Beneficiary withdraws consent
providers/partners Date (MM/DD/YYYY) Initials Date (MM/DD/YYYY) Initials
Past Care Coordination Org. (CCO)/Lead
Past CCO/Lead

Annual consent review date

Care coordinator name Care coordinator signature
(MM/DD/YYYY)

This release of information should include page 1 of the Health Home Participation Authorization and Information Sharing
Consent form in order to provide the legal authority to release information for the beneficiary listed above.
Details about the beneficiary information sharing and consent process:
1. How will providers/partners use my information?
Providers/partners will use your health information to coordinate and help you manage your health care.

2. Where does my health information come from?

Your health information comes from places and people that gave you health care or health insurance in the past. These may
include hospitals, doctors, pharmacies, laboratories, health plans, the Washington Apple Health (Medicaid) program, and
other groups that share health information. You can get a list of all the places and people by calling your care coordinator.

3. What laws and rules cover how my health information can be shared?
The laws and regulations that protect your health information include Chapter 70.02 RCW in Washington statute, the federal
Health Insurance Portability and Accountability Act (“HIPAA”), and federal regulation 42 CFR Part 2.

4. If I agree, who can obtain and see my information?

Your information may be obtained or seen by the providers/partners you agree can obtain and see it. Information can also
be obtained or seen when allowed by applicable laws. For example, when you get care from a person who is not your usual
doctor or provider, such as a new pharmacy, hospital, or other provider, some information, such as what your health plan pays
for or the name of your Health Home provider, may be given to them or seen by them. For more information on who can get
information, see our Notice of Privacy Practices.

5. What if a person uses my information and I did not agree to let them use it?
If you think a person inappropriately used your information, call your case coordinator or call the HCA Medical Assistance
Customer Service Center (MACSC) toll-free line at 1-800-562-3022 (TRS: 711).

6. How do I make changes to the list of providers/partners on the form?

You can add new names to the list at any time by adding the provider/partner information and filling out the “Beneficiary
Gives Consent” columns next to the addition. You can delete someone you no longer wish to include by filling out the
“Beneficiary Withdraws Consent” columns next to the previously added provider/partner.

7. What if I change my mind later and want to take back my consent?

You can cancel your consent at any time by signing a Health Home Participation - Opt-Out/Decline Services form and giving
it to your Care Coordinator. You get this form online or by calling the HCA Medical Assistance Customer Service Center
(MACSC) toll-free line at 1-800-562-3022 (TRS: 711). Your care coordinator will help you fill out this form if you want.

Note: If you decide to cancel your consent, providers who already have your information do not have to give your information
back to you or take it out of their records.

8. When do I get a copy of this Health Home Participation Authorization and Information Sharing Consent form?
You can have a copy of the form after you sign it.
 Health Home — Adolescent Information-Sharing Consent
You have been enrolled into Health Homes. Your health care providers and others involved in your care need to be able to talk
to each other about your health needs and care. At times, your health records may include information about:

 Family planning services, such as birth control and abortion

 HIV/AIDS
 Sexually transmitted diseases (diseases you can get from having sex)
 Mental health medications and services
 Chemical dependency services

Since this type of health information is private, the health care providers and others who have your health information cannot
give it to anyone unless you agree or the law allows it. This is true whether your health information is on a computer system or
on paper.
By signing this consent, you are agreeing that the people you have identified on this form have permission to view your private
confidential medical information and may consult with one another to help you manage your health care. This health information
may be from before or after the date you sign this form. Your health records may have information about illnesses or injuries you
have or may have had before; test results, such as x-rays or blood tests; and the medicines you are taking now or have taken
before.
If you are age 13 years and older and have been referred to Health Homes, you will be asked to sign this form, whether or not
this type of health information applies to you. If you do not sign this form, you will still be able to get Health Home services.

The laws that apply to these health records include:

 Sexually transmitted diseases: Revised Code of Washington (RCW) 70.24.105
 Mental health records: Revised Code of Washington (RCW) 71.05.620
 Chemical dependency: 42 Code of Federal Regulations (CFR) Part 2
I agree to allow Health Homes to receive and share my health information with the health care providers and others listed
on this form as it applies to:
All my client records, including reproductive health (i.e., birth control, pregnancy, abortion); HIV/AIDS and sexually
transmitted disease (STD) test results, diagnosis, or treatment; mental health; and chemical dependency.
OR
Only the following records (check all that apply):
HIV/AIDS and STD test results, diagnosis, or treatment
Reproductive health
Mental health
Chemical dependency
Other (list):
I also agree that the health care providers and others listed on this form may share my health information with each other, and
cannot share it with anyone who is not listed on this form. I can change my mind and take back my consent at any time by
updating page 2 of this form and giving it to my Health Home care coordinator. This will not affect any information already
shared. Initials:
Unless previously revoked by me, the specific information above is valid until:
I am no longer participating in Health Homes.
Or until _________________ (enter expiration date).
Print name of client Client’s date of birth

Client or legal representative’s signature Date

Print name of legal representative Relationship of legal representative to client

HCA 22-855 (6/15)

If you think someone used your information and you did not agree to give the person your information, call your care coordinator
or the Medical Assistance Customer Services Center (MACSC) toll-free line at 1-800-562-3022 (TTY: 1-800-848-5429).

Print name of client

Client gives Client withdraws
consent consent
List the names of participating health care providers and others
Client’s Client’s
Date Date
initials initials
Children’s Administration social worker

Natural parent, adoptive parent, foster parent

Primary care provider

Managed care organization

Past managed care organization

Health Home care coordinator/lead

Past Health Home care coordinator/lead

Tribal social worker/director

Family planning provider

Chemical dependency provider

Mental health provider

Additional care providers

NOTICE: PROHIBITING REDISCLOSURE OF CONFIDENTIAL ALCOHOL- OR DRUG-TREATMENT INFORMATION

This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the
consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules, 42
Code of Federal Regulations (CFR), Part 2. The federal rules prohibit you from making any further disclosure of this
information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as
otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is NOT
sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any
alcohol- or drug-abuse patient.
Release of Information (ROI) for
Substance Use Disorder (SUD) Services
I, , hereby authorize to release to:
Client name Date of birth Provider/Organization

Name of agency/health care provider Contact info

To communicate with and disclose to one another the following information: (nature of the information, as limited as possible)
Initial each category that applies:
Demographics Blood alcohol level Labs & other diagnostic test results
Assessment/screening results Medications Discharge summary
Urinalysis results Tx status/compliance Tx recommendations
Attendance Employment-related information Education and training-related information
Other:
Purpose of this release: (enter reason, i.e., client request, coordination of services, payment of services, etc.)

I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality
of Alcohol and Drug Abuse Patient Records, 42 Code of Federal Regulations (CFR) Part 2, and the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), 45 CFR, Parts 160 and 164, and cannot be disclosed without my written consent unless
otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that
action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
Specify the date, event, or condition upon which this consent expires. Initial each category that applies:
The date my public assistance/medical assistance benefits are discontinued, or
Other: (Specify earlier date if required by law)

[10][10]
Signature of patient Date

[10][10]
Signature of parent, guardian or authorized representative (when required) Date

Notice Prohibiting Redisclosure of Alcohol or Drug Treatment Information

Prohibition on Redisclosure of Confidential Information
This notice accompanies a disclosure of information concerning a client in alcohol/drug treatment, made to you with the consent
of such client. This information has been disclosed to you from records protected by federal confidentiality rules, 42 Code of
Federal Regulations (CFR), Part 2. The federal rules prohibit you from making any further disclosure of this information unless
further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42
CFR, Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal
rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

HCA 13-335 (03/16)

Health Home Participation (Opt-Out/Decline Services)
1 Applicant information

Client name Date of birth ProviderOne ID number

Qualified Health Home Lead Care Coordination Organization

Managed Care Organization (MCO) (if applicable

)

I have completed a Health Action Plan (HAP) I have not completed a Health Action Plan (HAP)

• The Health Home program has been explained to me and I have decided not to participate.

• I understand that I will continue to get my other Apple Health (Medicaid) services.

• If I want Health Home services in the future, I can call: 1-800-562-3022 (TRS: 711)
I am declining services because:

My benefits and services work for me. I do not need any help with my
medical and health care needs.

I am not comfortable with using this Other

benefit or program. Explain

2 Protecting your health information

When you opt out of Health Home services the following information is important for you to understand:

• Any previously signed Health Home Information Sharing Consent Forms are no longer valid.

• Your health information will be kept by providers/partners who already have your information. They do not have to give it
back to you or take it out of their records.

• Your personal health information will still be protected under Washington State and Federal laws and rules. These laws and
regulations include Washington State and federal confidentiality rules, RCW 71.05.630, RCW 70.24.105, RCW 70.02, the Uniform
Health Care Information Act, 42 CFR 2.31(a)(5), and include 45 CFR Parts 160 and 164, which are the rules referred to as
“HIPAA,” and 42 CFR Part 2. No one can obtain any new health information about you. Information already shared with others
will not be given back.

• If you think a person used your information, and you did not agree to give the person permission to use your information, call
your Care Coordinator or Apple Health customer service at 1-800-562-3022 (TRS: 711)

HCA 22-853 (1/23)

 3 Client signature

Client signature or authorized representative (if applicable

) Date signed

Print authorized representative’s name (if applicable)

4 Health Home Care Coordinator

I discussed the Health Home program with the client or authorized representative. The benefits were explained and they
decided not to participate or to end their participation in Health Home.

Signature of the Care Coordinator or Allied Staff Date signed

Name of Care Coordinator or Allied Staff

5 Care Coordinator or Allied Staff instructions

The Care Coordinator or Allied Staff is responsible for:

• Documenting the client’s request to opt-out or decline services, on this form and in the client’s case file.

• Signing on the Signature of the Care Coordinator or Allied Staff line after the form has been completed. If the client’s request to
opt-out or declines services is made over the phone, the client does not need to sign this form and the Care Coordinator or
Allied Staff must document the request on their behalf.

• Providing the client a copy of the form, in person or by mail.

• Ensuring that the Qualified Health Home Lead or MCO is provided with a copy of the form.

6 Qualified Health Home Lead or MCO instructions

The Qualified Health Home Lead or MCO must maintain this form and document on the Health Home Opt-Out Form
Registry, for monthly submission to the Health Care Authority.
 Health Home Incident Report
Care Coordination Organization
Care coordinator Care coordination organization Qualified Health Home lead entity/MCO

Date of incident Time of incident Location of Incident

AM PM
Beneficiary involved in the incident (name and ProviderOne ID if available) Date of birth

Briefly describe the incident Continue on the back if additional space is needed.

Did the incident lead to injury Was first aid or medical attention required?
Yes No
If first aid or medical attention was required, who provided the treatment? Office/hospital

Names of witnesses and/or other individuals involved

Care coordinator* signature Date

Supervising Organization (Qualified Lead or MCO)

Name of supervisor to whom this incident was Care coordinator organization Date Time
reported AM PM
List any planned actions including, but not limited to, training and policy initiatives.

Supervisor’s signature Date

What is an incident?
In the context of this form, an “Incident” is a negative event or occurrence which was not desired and/or anticipated, for which the
care coordinator* was present or came into contact, or was otherwise made aware of.
Instructions
After an incident, the care coordinator* must report the incident to their supervisor and complete the first portion of the Health
Home Incident Report form. Send a copy of the partially completed and signed form through secure email to
[email protected] within one working day, with “Health Home Incident Report Final” on the email subject line.
After the supervising organization portion of the form has been completed and signed, send the form through secure email to
[email protected], with Health Home Incident Report Final on the email subject line.
Copies of the final completed form should be supplied to the Health Home care coordinator and maintained on file with care
coordination organization and the qualified Health Home lead entity.
The completion of this form does not replace any required reporting to Adult Protective Services, Child Protective Services,
Residential Care Services Complaint Resolution Unit, Department of Health, law enforcement, and/or other mandatory reporting
agencies. Report abuse and neglect at: www.dshs.wa.gov/endharm.shtml
*Care coordinator, or other staff or volunteer, representing the care coordination organization or qualified Health Home lead entity.
HCA 22-813 (5/14)
Apple Health managed care
Service area map - January 2023

Whatcom Stevens Pend

San Juan North Okanogan Ferry Oreille
Sound
AMG
CCW Skagit North Central Spokane
CHPW AMG CCW CHPW MHW
Island AMG
MHW
CCW
UHC
Clallam CHPW
MHW
Snohomish Chelan
Salish Jefferson
Douglas
AMG CCW CHPW MHW UHC
Kitsap King Lincoln Spokane
AMG MHW
Thurston- CCW UHC
Grays Mason CHPW
King
Harbor AMG
CCW Kittitas Grant
CHPW Pierce
MHW Pierce Adams Whitman
UHC AMG CCW CHPW
Thurston MHW UHC
Yakima
Pacific
Pacific Great Rivers
AMG CCW CHPW MHW UHC Lewis Franklin Garfield
Greater Columbia
AMG CCW CHPW MHW
Columbia
Wahkiakum Cowlitz
Cowlitz Skamania
Benton Walla Walla Asotin
Southwest
AMG CCW CHPW MHW Klickitat
Clark

Integrated managed care regions Health plans offered

Greater Thurston-Mason AMG – Amerigroup Washington

Columbia CCW – Coordinated Care of Washington
CHPW – Community Health Plan of Washington
King Salish MHW – Molina Healthcare of Washington
UHC – UnitedHealthcare Community Plan
North Sound Great Rivers

Pierce Southwest Washington

Spokane North Central

Apple Health Foster Care (statewide)

 Apple Health Foster Care is a statewide program. Integrated managed care is provided
through Apple Health Core Connections (Coordinated Care of Washington - CCW).

HCA 19-0036 (10/22)

Behavioral Health-Administrative Services Organizations (BH-ASO)
Counties in each BH-ASO Whatcom
Okanogan Ferry Stevens Pend
Greater Columbia Thurston-Mason San Juan Oreille
Asotin, Benton, Columbia, Mason, Thurston North Sound
Franklin, Garfield, Kittitas,
Walla Walla, Whitman, Island
Skagit North Central Spokane
Yakima Clallam

King Salish
King Clallam, Jefferson, Salish Snohomish Chelan
Kitsap Jefferson Kitsap Douglas
Mason King Lincoln Spokane
Grays
Harbor Thurston-
North Sound Great Rivers Mason Kittitas Grant
Island, San Juan, Cowlitz, Grays Harbor, Adams Whitman
Snohomish, Skagit, Lewis, Pacific, Pierce
Whatcom Wahkiakum
Yakima
Great Rivers Franklin Garfield
Pacific Lewis
Carelon Behavioral Carelon Behavioral Columbia
Health - Pierce Health - Southwest Greater Columbia
Wahkiakum Cowlitz Skamania Walla Walla Asotin
Pierce Clark, Klickitat,
Benton
Skamania
Southwest Klickitat
Clark
Spokane Carelon Behavioral
Adams, Ferry, Lincoln, Health - North Central
Pend Orielle, Spokane, Chelan, Douglas,
Stevens Grant, Okanogan

Regional crisis assistance (24/7/365) for mental health and substance use disorder
crises available to all individuals, regardless of their insurance status or income level.
HCA 19-0040 (11/23)
 FOR CLIENT S

Care Coordination for a Healthier You

The Health Home Program provides care
coordination of medical, behavioral health
and long-term services and supports for
individuals of all ages.
This program is an extra Medicaid benefit
available at no cost to you. Your Health Home
connects a network of your current providers
along with local organizations and agencies
that work together to provide support to you.
Medicaid clients of all ages and Medicaid
clients who also receive Medicare may be
eligible for Health Home services.

Health Home Care Coordinators:

• Supports you in improving your quality of life
• Helps with post-hospital care
• Helps you manage multiple providers
• Assists you in getting
appointments
• Identifies helpful community
resources
• Helps connect you to available
benefits

Visit the web site:

www.hca.wa.gov/billers-providers-partners/programs-and-services/health-homes
[email protected]
DSHS 22-1588 (Rev. 8/22) 1-800-562-3022
 FOR PROVIDER S

Washington Health Home Program

Care Coordination for Healthier Clients
The Health Home Program provides care
coordination of medical, behavioral health and
long-term services and supports for eligible
individuals of all ages, at no cost to you or
your client. The program uses a network of
local agencies that work together to help
clients understand and manage their health
concerns. This helps reduce dependence on
emergency departments and prevents avoidable
hospitalizations.

Health Home Care Coordinators:

• Help coordinate services for eligible Medicaid clients with chronic
and complex medical and social needs
• Provide appointment assistance
• Identify gaps in care and remove barriers
• Connect clients to a broad range of benefits such as, medical and
behavioral health services, long-term services and supports,
and other social services
• Support successful transition from
hospital to other levels of care
• Link clients to community services
• Support improved quality of life
• Helps establish primary care
relationships
For More Information:
www.hca.wa.gov/billers-providers-partners/programs-and-services/health-homes

[email protected]
1-800-562-3022