Adult Ambulatory Core Components and Milestones: Primary Care and Behavioral Health

Below are the Core Component and Milestone documents for the Adult Behavioral Health and Primary Care Areas of Concentration. Each document provides a summary of due dates for Milestones, detailed descriptions of Core Components, and a list of resources to help you complete Milestones.

TI Program Year6 Core Components and Milestones

TI Program Year 4 & 5 Core Components and Milestones

TI Program Years 2 & 3 Core Components and Milestones

Hospital Project
Core Component	Milestone	Due Date	Module-CBT Version	Module-PDF Version
N/A	Orientation Module	N/A	Orientation	Orientation
1	Develop protocols to identify members’ primary care physicians and to obtain members health history	9/30/18	N/A	Hospital Module**
2	Make direct connections to community behavioral health providers	9/30/18	--	--
3	Schedule follow-up with behavioral health provider within 7 days of patient discharge	9/30/18	--	--
4	Conduct a review within 48 hours of discharge	9/30/18	--	--
5	Provides priority medications in sufficient amounts for patients	9/30/18	--	--
6	Participate in relevant TI program-offered training	N/A	--	--

** Hospital Module encompasses all six Core Components outlined in TI Year 2.

Adult BH Ambulatory Project
Core Component	Milestone	Due Date	Module-CBT Version	Module-PDF Version
N/A	Orientation Module	N/A	Orientation	Orientation
1	Utilize a behavioral health integration toolkit and action plan and determine level of integration	5/31/18	CC #1	CC #1
2	Implement the use of an integrated care plan	9/30/18	CC #2	CC #2
3	Screen members using SDOH and develop procedures for intervention	9/30/18	CC #3	CC #3
4	Develop communication protocols with MCO’s and providers	9/30/18	CC #4	CC #4
5	Participate in the health information exchange with Health Current	9/30/18	CC#5	CC#5
6	Identify community based resources	9/30/18	CC #6	CC #6
7	Participate in relevant TI program-offered training	N/A	No Module	No Module

Adult PCP Ambulatory Project
Core Component	Milestone	Due Date	Module-CBT Version	Module-PDF Version
N/A	Orientation Module	N/A	Orientation	Orientation
1	Utilize a behavioral health integration toolkit and practice-specific action plan to improve integration and identify level of integrated healthcare	5/31/18	CC #1	CC #1
8	Utilize the Arizona Opioid Prescribing Guidelines for chronic pain	5/31/18	N/A	CC #8
2	Identify members who are high-risk and develop electronic registry; Demonstrate use of identification criteria and document members in registry	8/31/18 9/30/18	CC #2	CC #2
3	Utilize care managers for members in high-risk registry; Demonstrate that care manager(s) are trained in integrated care	9/30/18	CC #3	CC #3
4	Implement integrated care plan	9/30/18	CC #4	CC #4
5	Screen all members to assess SDOH	9/30/18	CC#5	CC#5
6	Develop communication protocols with physical health and behavioral health providers for referring members	9/30/18	CC #6	CC #6
7	Screen all members for behavioral health disorders	9/30/18	CC #7	CC #7
9	Participate in the health information exchange with Health Current	9/30/18	CC #9	CC #9
10	Identify community-based resources	9/30/18	CC #10	CC #10
11	Prioritize access to appointments for all individuals listed in high-risk registry	9/30/19	N/A	N/A
12	Participate in any TI program-offered training	N/A	No Module	No Module

Justice Ambulatory Project
Core Component	Milestone	Due Date	Module-CBT Version	Module-PDF Version
N/A	Orientation Module	N/A	Orientation	Orientation
1	Utilize a behavioral health integration toolkit and practice-specific action plan to improve integration, and identify level of integrated healthcare	6/30/18	CC #1	CC #1
2	Develop high-risk registry and develop criteria used to identify high-risk members	9/30/18	CC #2	CC #2
3	Use practice care managers for members included in the high-risk registry Demonstrate care manager is trained in integrated care	9/30/18 12/30/18	CC #3	CC #3
4	Implement integrated care plan	9/30/18	CC #4	CC #4
5	Screen members using SDOH and procedures for intervention	9/30/18	CC#5	CC#5
6	Develop communication protocols with MCO’s and providers	9/30/18	CC #6	CC #6
7	Screen all members for behavioral health disorders	9/30/18	CC #7	CC #7
8	Provide attestation to verify you will begin utilizing the Arizona Opioid Prescribing Guidelines for chronic pain	9/30/18	N/A	CC #8
9	Participate in the health information exchange with Health Current	9/30/18	CC #9	CC #9
10	Identify community-based resources	9/30/18	CC #10	CC #10
11	Prioritize access to appointments for all individuals listed in high-risk registry	9/30/19	N/A	N/A
12	Establish contracts with MCOs for reimbursement	9/30/18	CC #12	CC #12
13	Establish integrated care in probation/parole office	9/30/18	CC #13	CC #13
14	Develop outreach plan	9/30/18	CC #14	CC #14
15	Include practice care managers in care plan	9/30/18	CC #15	CC #15
16	Create Access to MAT	9/30/18	CC #16	CC #16
17	Create peer/family support plan	9/30/18	CC #17	CC #17
18	Participate in relevant TI program-offered training	N/A	N/A	N/A

Pediatric BH Ambulatory Project
Core Component	Milestone	Due Date	Module-CBT Version	Module-PDF Version
N/A	Orientation Module	N/A	Orientation	Orientation
1	Utilize a behavioral health integration toolkit and practice-specific action plan to improve integration, and identify level of integrated healthcare	5/31/18	CC #1	CC #1
2	Implement the use of an integrated care plan	9/30/18	CC #2	CC #2
3	Screen members using SDOH and develop procedures for intervention	9/30/18	CC #3	CC #3
4	Develop communication protocols with MCO’s and providers	9/30/18	CC #4	CC #4
5	Screen children from ages 0–5 using the Early Childhood Service Intensity Instrument (ECSII)	9/30/18	CC#5	CC#5
6	Participate in the health information exchange with Health Current	9/30/18	CC #6	CC #6
7	Identify community-based resources	9/30/18	CC #7	CC #7
8	Develop protocols for Trauma-Informed Care for those in the high-risk registry	9/30/18	CC #8	CC #8
9	Develop communication protocols in agreement with ASD	9/30/19	N/A	N/A
10	Develop procedures to provide information to families with children/youth with ASD	9/30/19	N/A	N/A
11	Develop protocols for those with ASD to facilitate transitions from pediatric to adult providers	9/30/19	N/A	N/A
12	Develop a protocol for obtaining records for those in child welfare system and medication needs.	9/30/19	N/A	N/A
13	Complete after-visit summary for foster parents/guardians/case worker with recommendations and confidentiality policy	9/30/19	N/A	N/A
14	Participate in relevant TI program-offered training	9/30/19	N/A	N/A

Pediatric PCP Ambulatory Project
Core Component	Milestone	Due Date	Module-CBT Version	Module-PDF Version
N/A	Orientation Module	N/A	Orientation	Orientation
1	Utilize a behavioral health integration toolkit and practice-specific action plan to improve integration, and identify level of integrated healthcare	5/31/18	CC #1	CC #1
8	Utilize the Arizona Opioid Prescribing Guidelines for chronic pain	5/31/18	N/A	CC #8
2	Identify high-risk members and develop an electronic registry Identify criteria is being used and recorded	8/31/18 9/30/18	CC #2	CC #2
3	Utilize practice care manager(s)for members included in the high-risk registry Demonstrate the care manager(s)have been trained to use integrated care plans	9/30/18	CC #3	CC #3
4	Implement the use of an integrated care plan and develop communication protocols with MCO’s and providers	9/30/18	CC #4	CC #4
5	Screen all members to assess SDOH	9/30/18	CC#5	CC#5
6	Identify community based resources	9/30/18	CC #6	CC #6
7	Screen all members for behavioral health disorders	9/30/18	CC #7	CC #7
9	Participate in the health information exchange with Health Current	9/30/18	CC #9	CC #9
10	Identify community-based resources, at a minimum through use lists managed by MCO’s	9/30/18	CC #10	CC #10
11	Prioritize access to appointments for all individuals listed in high-risk registry	9/30/19	N/A	N/A
12	Develop protocols for using Trauma-Informed Care for those in the high-risk registry	9/30/18	CC #12	CC #12
13	Develop communication protocols in agreement with ASD	9/30/19	N/A	N/A
14	Ensure medical staff complete ASD training program	9/30/18	CC #14	CC #14
15	Develop procedures to provide parent support	9/30/19	N/A	N/A
16	Develop protocols for those with ASD to facilitate transitions from pediatric to adult providers	9/30/19	N/A	N/A
17	Develop a protocol for obtaining records for those in child welfare system and their medication needs	9/30/19	CC#17	CC#17
18	Schedule office visits for children/youth in welfare system	9/30/18	CC #18	CC #18
19	Complete after-visit summary for foster parents/guardians/case worker with recommendations and confidentiality policy	9/30/19	N/A	N/A
20	Participate in relevant TI program-offered training	N/A	No Module	No Module