SECTION 450:55-25-1. Program description and purpose

(a)   The purpose of this Subchapter is to set forth, in addition to all other applicable rules, rules regulating program requirements, activities, and services for PACT Programs who opt to deliver services through a Behavioral Health Home model.

(b)   The purpose of BHHs within the mental health delivery array is to promote enhanced integration and coordination of primary, acute, behavioral health, and long-term services and supports for persons across the lifespan with chronic illness, including adults with serious mental illness (SMI). Care must be delivered using an integrated team comprehensively address physical, mental health, and substance use disorder treatment needs.

(c)   The BHH must maintain facility policies and program descriptions that clearly describe that the purpose of the BHH is to improve the health status of individuals with Serious Mental Illness by integrating behavioral and primary health care and promoting wellness and prevention.

(d)   The BHH must provide program descriptions and demonstrate evidence that the following functions are implemented.

(1)   Quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services;

(2)   Coordinated access to:

(A)   High-quality health care services informed by evidence-based clinical practice guidelines;

(B)   Preventive and health promotion services, including prevention of mental illness and substance use disorders;

(C)   Mental health and substance abuse services;

(D)   Comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care;

(E)   Chronic disease management, including self-management support to individuals and their families;

(F)   Individual and family supports, including referral to community, social support, and recovery services; and,

(G)   Long-term care supports and services;

(3)   Person-centered care plans for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services;

(4)   Proper and continuous use of health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and

(5)   A quality improvement program, which collects and reports on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level.

(e)   Compliance with this Section will be determined by on-site observation, review of organizational documents, program descriptions, outcome monitoring and other performance improvement activity reports, and clinical records.

[Source: Added at 32 Ok Reg 478, eff 1-1-15 (emergency); Added at 32 Ok Reg 2131, eff 9-15-15; Amended at 35 Ok Reg 1860, eff 10-1-18]