Integrated Care; Health Homes Definition
Purpose
Adults and children who receive integrated care experience improved health care quality, an improved client care experience, and improved clinical and non-clinical outcomes.Definition
Behavioral health providers can offer integrated care by fully integrating primary care into their existing program, establishing written agreements with a primary care provider that is located on-site, or establishing written agreements with a primary care provider that is located in the community.
Health home services that are eligible for federal reimbursement as authorized by the ACA include:
- comprehensive care management;
- care coordination and health promotion;
- comprehensive transitional care, including appropriate follow-up from inpatient to other settings;
- individual and family support;
- referral to community and social support services, as applicable; and
- the use of health information technology (HIT) to link services.
Examples: Chronic conditions include, but are not limited to, substance use disorders, mental health conditions, asthma, diabetes, heart disease, and having a Body Mass Index (BMI) over 25.
Note:Throughout the PA-ICHH standards, the involvement of the person’s family has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law.
Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child.
Note:Please see PA-ICHH Reference List for the research that informed the development of these standards.
Note:For information about changes made in the 2020 Edition, please see the ICHH Crosswalk.
Integrated Care; Health Homes (PA-ICHH) 1: Person-Centered Logic Model
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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No On-Site Evidence
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PA-ICHH 1.01
- needs the program will address;
- available human, financial, agency, and community resources (i.e. inputs);
- program activities intended to bring about desired results;
- program outputs (i.e. the size and scope of services delivered);
- desired outcomes (i.e. the changes you expect to see in service recipients); and
- expected long-term impact on the agency, community, and/or system.
Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to:
- needs assessments and periodic reassessments; and
- the best available evidence of service effectiveness.
PA-ICHH 1.02
- change in clinical status;
- change in functional status;
- health, welfare, and safety;
- permanency of life situation;
- quality of life;
- achievement of individual service goals; and
- other outcomes as appropriate to the program or service population.
Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PA-PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes.
- body mass index;
- screening for clinical depression;
- hospital admissions and readmissions;
- emergency room visits;
- skilled nursing facility admissions;
- initiation and engagement of alcohol and other drug use treatment;
- tobacco use;
- appointment attendance; and
- measures related to chronic medical conditions such as hypertension, diabetes, and asthma.
- body mass index;
- immunization status;
- well-child visits;
- school attendance;
- placement disruptions in child welfare;
- juvenile justice recidivism;
- residential placements;
- hospital admissions and readmissions;
- measures related to chronic conditions such as asthma, diabetes, and ADHD; and
- other clinical and functional outcomes found on standardized, child-oriented tools such as the Child and Adolescent Needs and Strengths (CANS).
Integrated Care; Health Homes (PA-ICHH) 2: Personnel
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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PA-ICHH 2.01
- coordinating and providing access to needed services;
- facilitating transition planning and coordination;
- applicable evidence-based interventions;
- physical health issues commonly associated with mental health or substance use conditions;
- health conditions and treatment responses particular to the service population;
- chronic disease management, including promoting self-management;
- developing a person- or family-centered care plan;
- understanding the roles played by different child-serving systems, as applicable; and
- using health information technology to link services and facilitate collaboration among providers, the person, and his or her family.
PA-ICHH 2.02
- assigning the care planning team at intake or early in the contact; and
- avoiding the arbitrary or indiscriminate reassignment of direct service personnel.
PA-ICHH 2.03
- the qualifications, competencies, and experience of the worker including the level of supervision needed;
- services provided by other professionals or team members;
- the work and time required to accomplish assigned tasks and job responsibilities; and
- service volume, accounting for assessed level of needs of persons served.
Integrated Care; Health Homes (PA-ICHH) 3: Administrative Practices
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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PA-ICHH 3.01
PA-ICHH 3.02
- the scope of services offered directly by the agency;
- how information will be shared both internally and externally among collaborating providers; and
- the nature of the relationship that exists between providers when direct services are provided through contract or other agreement between separate legal entities.
PA-ICHH 3.03
- link services including shared access to the person's health information;
- organize, track, and analyze critical program information including referrals and needed follow-up; and
- satisfy applicable reporting requirements.
Integrated Care; Health Homes (PA-ICHH) 4: Assessment
Currently viewing: ASSESSMENT
VIEW THE STANDARDS
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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PA-ICHH 4.01
Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.
PA-ICHH 4.02
- basic needs including food, clothing and shelter;
- the person's behavioral health, physical health, and community and social support service needs and goals;
- history of trauma;
- relevant systems involvement;
- individual and family strengths, risks, and protective factors;
- natural supports and helping networks; and
- the impact of the individual’s health care needs on the family unit.
PA-ICHH 4.03
- the person;
- the person’s family;
- medical and/or clinical case records;
- the results of screening tools;
- relevant content from assessments completed by partnering or referring providers;
- other providers; and
- members of the care planning team.
- gaps in information;
- out-of-date information; and
- information that can be used to minimize duplication of effort.
PA-ICHH 4.04
- giving priority to urgent needs and emergency situations;
- expedited care planning;
- connecting the individual to more intensive services as needed;
- facilitating the development of a safety and/or crisis plan; and
- contacting emergency responders as appropriate.
PA-ICHH 4.05
Integrated Care; Health Homes (PA-ICHH) 5: Care Planning and Monitoring
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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No On-Site Evidence
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PA-ICHH 5.01
- the person's behavioral health, physical health, and community and social support service needs and goals, including basic needs when applicable;
- steps for working toward achievement of desired goals including timeframes where appropriate;
- services and supports to be provided, and by whom;
- possibilities for maintaining and strengthening family relationships and other informal social networks;
- agreed upon timelines for conducting regular case reviews; and
- documentation of the individual’s or family’s involvement in care planning.
PA-ICHH 5.02
- continued accuracy of the assessment;
- care plan implementation;
- the person’s continued engagement in his or her treatment;
- the person’s progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of agreed upon service goals.
PA-ICHH 5.03
- regularly review progress toward achievement of agreed upon goals; and
- sign revisions to service goals and plans.
Integrated Care; Health Homes (PA-ICHH) 6: Care Coordination
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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PA-ICHH 6.01
- a designated care coordinator with qualifications appropriate to the needs of the identified service population;
- a primary care professional such as a physician’s assistant or nurse practitioner with access to a physician for needed consultation;
- a behavioral health professional such as a social worker, psychologist, or other licensed clinician with access to a psychiatrist for needed consultation; and
- other providers and supports based on the needs of the individual.
Examples: Agencies can leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical.
Examples: Supports that may also be included on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual.
PA-ICHH 6.02
PA-ICHH 6.03
- establishing partnerships and coordination procedures with direct service providers in the community;
- establishing communication procedures with persons served and across disciplines, both internally and externally;
- maintaining a comprehensive, up-to-date referral list;
- removing barriers to the initiation of needed services including procedures for providing a warm hand off when needed services are provided directly by the program or on-site through a partnering provider; and
- assisting the person with system navigation.
- preventative and health promotion services;
- mental health and substance use services;
- comprehensive care management, care coordination, and transitional care;
- chronic disease management, including self-management;
- community, social support, and recovery services;
- peer support services; and
- long-term care supports and services.
PA-ICHH 6.04
- ensure the service was received;
- identify any needed follow-up; and
- make needed changes to the care plan in partnership with the person and his or her family.
PA-ICHH 6.05
- coordinating information sharing and service provision with providers and the person;
- developing, or supporting the development of, a comprehensive discharge or transition plan with steps for follow-up; and
- facilitating face-to-face interactions between providers, whenever possible.
PA-ICHH 6.06
- conducts medication reconciliation and adherence; or
- tracks that it is being done by another provider as part of their care coordination activities.
PA-ICHH 6.07
- linkages to community providers as well as completed follow-up;
- communication with partnering providers both internally and externally; and
- communication with the person.
Integrated Care; Health Homes (PA-ICHH) 7: Health Promotion
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.
- All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance.
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
- The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.
- Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.
- The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.
- Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.
- Service quality or agency functioning may be compromised.
- Capacity is at a basic level.
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.
- The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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No Self-Study Evidence
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PA-ICHH 7.01
PA-ICHH 7.02
- individual characteristics and abilities; and
- evidence-based practices and concepts.
PA-ICHH 7.03
PA-ICHH 7.04
- connecting individuals and families to informal support systems in their community; and
- educating individuals and families on where to access needed services.