Fillable Mih Application Form Updated (Commonwealth of Massachusetts)

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Mih Application Form Updated (Commonwealth of Massachusetts)

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The Mih Application Form Updated (Commonwealth of Massachusetts) form is 17 pages long and contains:

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  • 23 check-boxes
  • 74 other fields

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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1
CHARLES D. BAKER
Governor
KARYN E. POLITO
Lieutenant Governor
MARYLOU SUDDERS
Secretary
MONICA BHAREL, MD,
MPH Commissioner
Tel: 617-624-6000
www.mass.gov/dph
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Health Care Safety and Quality
Office of Emergency Medical Services
Mobile Integrated Health Care Program
67 Forest Street, Marlborough MA 01752
Application for Approval
Mobile Integrated Health Care
INSTRUCTIONS
This application form is to be completed by any health care entity that wishes to
apply for a Certificate of Approval to operate a Mobile Integrated Health Care (MIH)
Program for proposed services in Massachusetts. If seeking a Certificate of Approval
for an MIH Program with Emergency Department (ED) Avoidance component, the
applicant must also submit a separate ED Avoidance component application,
with all required attachments, responses, and ED Avoidance component
application fee. If seeking approval for a Community EMS Program, please do not
complete this application and instead complete the Community EMS Program
application.
Unless indicated otherwise, all responses must be submitted in the format
specified. Handwritten responses will not be accepted.
Attachments should be labeled or marked so as to identify the question to which it
relates.
MIH applicants must submit a non-refundable application fee along with their
application. Information on fee amounts as well as the MIH Program Application
Remittance Forms, which must be submitted along with fee payments, can be found in
the application section of the MIH website at https://www.mass.gov/how-to/apply-to-
operate-an-mih-program.
Pursuant to 105 CMR 173.030(A), the DPH will expedite review of applications with a
focus on underserved populations, such as behavioral health patients.
REVIEW
After a completed application and fee are received by the Department of Public Health
(Department), the Department will review the information and will contact the applicant
if clarifications or additional information for the submitted application materials are
needed.
2
REGULATIONS
For complete information regarding approval of an MIH Program, please refer to
105 CMR 173.000 and associated sub-regulatory guidance. It is the applicant’s
responsibility to ensure that all responses are consistent with the requirements
of 105 CMR 173.000 and associated sub-regulatory guidance, and any
requirements specified by the Department, as applicable.
QUESTIONS
If additional information is needed regarding the MIH application process, please
contact the MIH Program at 617-753-8484 or MIH@state.ma.us.
APPLICATION ATTACHMENT CHECKLIST
This application
If applicable, list of ESP partners and description of how program will address
patients with behavioral health needs.
Executive Summary (2.a.)
Gap in service delivery narrative (3.a.)
Coordination of care and partnership description and documentation (4.a.)
911 EMS systems coordination and service duplication description (4.b.)
Organizational readiness description, organizational chart, and roles (5.a.)
MIH Program Compliance and Capacity form (5.b.)
Medical control and medical direction description, Medical Director
biography,medical oversight plan (6.a.)
Application Resubmission. If this is a resubmission, please include your
previous application number in the box on the below. Your application
number or ID is provided on the last page of the previous application if it was
saved.
Initial Application Number: _________________
To submit this application and all required supporting documentation, please
fax the documents to 617-887-8751. Applicants must label all supporting
documents with the 14-digit application number found on the last page of this
application.
3
1. APPLICANT INFORMATION
* Name of Applicant
Organization:
(name by which you will
conduct business)
* Address of Applicant
Organization:
* Street
* City
* S
tate
* Zip Code
*Last Name,
First Name of
Contact Person:
* Title:
* Email
Address:
* Title:
* Email
Address:
* Telephone Number:
* Name of Medical
Director:
* Telephone Number:
* Name of Authorized
Authorized Signatory:
* Ambulance
Telephone Number:
Title:
* Ambulance
E-Mail
* Total EMS Personnel
FTEs in Propos
ed
P
rogram:
* Paramedic
FTEs in
P
roposed
P
r
ogram:
* Program Funding:
Agency funds Grant support 3
rd
party payers
Tax revenue Other (describe): __________________________
Signatory:
Please refer to the instructions document on how to create an e-signature located at:
https://www.mass.gov/how-to/apply-to-operate-an-mih-program
* Signature of
* Date:
* Date:
* Name of
Ambulance Service:
* Am
bulance
Contact Person
:
Address:
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4
If the proposed program intends to serve MassHealth beneficiaries with behavioral
health needs, please attach a description of how you will partner or coordinate with ESP(s)
and list the ESP partners.
Please list all health care entities and associated contacts with which you have
proposed operational partnerships: Please include ambulance services, hospitals,
health plans/insurers, physician practices/medical homes, and any other
organizations
Contact Last Name, First name
Proposed
Operational Partner
Contact Email Address
5
_________________________________________________
* Signature of Authorized Signatory of Applicant Organization
_____________________
___________________________________________________________________________
* Print Name of Authorized Signatory of Applicant Organization
___________________________________________________________________________
* Title of Authorized Signatory of Applicant Organization
__________________________________
* Signature of Medical Director
___________________________________________________________________________
* Print Name of Medical Director
___________________________________________________________________________
* Title of Medical Director
______________________________________________________________________
* Date Signed
_____________________
* Date Signed
Attestation:
In accordance with 105 CMR 173.000, the undersigned hereby applies for designation to
establish a Mobile Integrated Health Care Program as set forth under provisions of 105
CMR 173.000.
The undersigned representative(s) of the applying organization hereby attest that, (1)
the information provided in and submitted with this document is accurate and correct
to the best of my knowledge; (2) the failure to file a complete and accurate application
for approval or renewal may constitute grounds for denial or revocation of approval;
and, (3) pursuant to the applying organization’s responsibility as an approved Mobile
Integrated Health Care Program to comply with 105 CMR 173.000, the applying
organization acknowledges and understands the regulatory requirements of 105 CMR
173.000 and associated guidance documents, and is in compliance with the regulatory
requirements of 105 CMR 173.000, and can provide verification of compliance upon
request.
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6
2. PROPOSED PROGRAM OVERVIEW
a. Please attach an executive summary which outlines a description of the
proposed program, including purpose and goals of the program, key organizations
and partners involved operationally in the proposed program, and the proposed
service(s) that would be provided.
3. GAPS IN SERVICE DELIVERY
a. Please attach a gap in service delivery narrative no longer than five pages
per proposed service. The gap in service delivery narrative should use data,
leverage a corresponding community health needs assessment, and be crafted in
accordance with the Guidance for Preparing a Gap in Service Delivery Narrative.
b. Please check which of the following improvements are addressed by each
of your proposed service(s), and list the corresponding service(s) that
apply for each improvement checked in the table below. The proposed
service(s) should provide improvements in quality, access, and cost
effectiveness, provide an increase in patient satisfaction, provide an increase in
patients’ quality of life, and provide an increase in interventions that promote
health equity, including cultural and linguistic competencies.
At least one box besides “Other” must be checked for each proposed service to
qualify as complete.
7
Improvement in clinical care coordination,
including, but not limited to the
patient’s adherence to medication and
other therapies previously prescribed by
the patient’s Primary Care Provider
Other
4. PARTNERSHIPS & COORDINATION OF CARE
a. Please attach a description of how the proposed program will
ensure coordination of care between partners, and include documentation
such as memoranda of understanding, letters of intent, or contracts detailing
any existing or proposed operational partnerships, contracts, agreements,
affiliations, or formal relationships between the proposed program and any
health care or related entities (i.e. ambulance services, hospitals, physicians
practices, referral agencies, provider agencies, public health entities). If the
proposed program does not intend to partner with other health care providers,
please describe how the program will ensure coordination of care with an MIH
patient’s primary care provider, or if the patient does not have a primary care
provider, with the patient’s associated health care entity to establish a primary care
relationship.
Improvement
Proposed service(s) that apply (Please list)
A decrease in total medical expenditures
An increase in access to medical or follow-
up care under the direction of the patient’s
Primary Care Provider
A decrease in cost to patient
A decrease in time to appropriate patient
care in an appropriate health care setting
A decrease in avoidable emergency
department visits or hospital readmissions
8
b. Please attach a description of the proposed
coordination and
interaction with applicable 911 EMS systems in accordance with the provision
of 105 CMR 170.000, including affirmation that the proposed program
has policies and procedures that address the management of patients who
experience a medical emergency and require activation of the 911 EMS
system, and affirmation that if an MIH Program’s on-scene personnel, after
assessment and in accordance with medical direction, determines that
the patient is experiencing a medical emergency, the MIH Program’s
on-scene personnel will activate the 911 EMS system and continue to
assess and treat the patient in accordance with clinical protocols until
transfer of care to the responding ambulance service in accordance with 105
CMR 170.355(B)(2) and (4), Department-established guidance, and the
applicable service zone plan. Description should also include how the
proposed program will deliver health care services without duplicating services.
5. ORGANIZATIONAL READINESS
a. Please attach a description of the proposed program’s organizational
readiness, including demonstrating that it has sufficient capacity to develop and
operate the proposed program and to provide the proposed service(s).
Sufficient capacity may be demonstrated through financial and legal viability
information, and sustainability and compliance history. Please include an
organizational chart specific to the applicant organization’s management and
operational structure in the field, and description of roles for the proposed MIH
program.
b. Please attach a completed MIH Program Compliance and Capacity Form.
c. I attest to the proposed MIH Program’s organizational readiness and ability to
meet appropriate standards regarding operations, location, personnel, equipment,
and medical devices.
__________________________________________
* Signature of Authorized Signatory of Applicant Organization
____________________________________________________________________
* Print Name of Authorized Signatory of Applicant Organization
____________________________________________________________________
* Title of Authorized Signatory of Applicant Organization
_____________________
* Date Signed
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9
6. MEDICAL OVERSIGHT
a. Please attach a description of how the proposed program will provide
access to qualified medical control and medical direction. In addition, please:
I. Include the Medical Director’s biography
II. Include the proposed program’s plan for medical oversight, including
lines of authority and responsibility, development and review of clinical
protocols, training and assessment of skills, communication systems, and
continuous quality assurance and improvement.
b. I attest that the proposed MIH Program’s designated Medical Director has
complete medical oversight over all clinical aspects of the proposed program. I
attest that the proposed MIH Program’s Medical Director approves of the
clinical protocols, and that the program has documentation addressing all
relevant clinical protocols, training content, skill assessment processes, and a
description of responsibilities of the medical director. I attest that the medical
director shall have responsibilities that include but are not limited to:
I. Developing and updating clinical protocols appropriate to:
i. the unique medical needs of the MIH Program’s patient population; and,
ii. the particular personnel providing MIH services, including, but not limited
to, Community Paramedics, EMS Personnel, Nurses, Nurse Practitioners,
Physician Assistants and others;
II. Granting authorization to practice to Community Paramedics and other
EMS Personnel providing health care services on behalf of MIH Programs;
III. Ensuring that all MIH Program personnel are properly trained and
provide health care services or treatment:
i. within the scope of their practice;
ii. in accordance with the clinical protocols developed for the MIH Program;
and,
ii. in accordance with any additional training required by Department
guidelines;
10
c. Furthermore, I attest that policies and procedures include a process for
obtaining a patient’s informed consent at each clinical encounter and a process
for coordinating care with a patient’s primary care provider, or associated health
care entity to establish a primary care relationship
d. Furthermore, I attest that the program will deploy a vehicle appropriate for the
clinical encounter, and that all regulatory and manufacturer requirements specific to
equipment, supplies and medications will be adhered to when responding to a MIH
call or for a scheduled home visit.
__________________________
*Signature of Medical Director
______________________________________________________________________
* Print Name of Medical Director
_____________________________________________________________________
* Title of Medical Director
____________________
* Date Signed
IV. Ensuring that the MIH Program maintains a secure and effective
telecommunication system and that all online medical direction is recorded;
V. Making online medical direction available to MIH Program personnel during
all hours of operation;
VI. Ensuring that all physicians and other primary care providers who provide
online medical direction to MIH Program personnel receive appropriate training
in:
i. the scope of practice of each type of MIH Program personnel;
ii. the specific clinical protocols developed for the MIH Program; and,
iii. any additional training required by Department guidelines; and,
VII. Coordinating the MIH Program’s continuous quality assurance and
improvement program.
11
To submit this application and all required supporting documentation,
please fax the documents to 617-887-8751. Applicants must label
all supporting documents with the 14-digit application number as
found above in red on this page of this application.
This document is ready to submit: Date:
Your Application Number:
Use this number on all communications regarding this application.
Document ready for submission
1. When the document is complete click on "Document is ready to submit". This will
generate an application number, lock the responses, generate today’s date and
time-stamp the form.
2. Please keep a copy for your records by clicking on the "Save" button at the bottom
of the page.
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Mih Application Form Updated (Commonwealth of Massachusetts)

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Completed 22 July 2020

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