Fillable Mih Eda Application Form Updated (Commonwealth of Massachusetts)

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Mih Eda Application Form Updated (Commonwealth of Massachusetts)

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  • 16 check-boxes
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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
99 Chauncy Street, 11
th
Floor, Boston, MA 02111
Application for Approval
Mobile Integrated Health Care with ED
Avoidance Component
INSTRUCTIONS
This application form is to be completed by a health care entity applicant that is
partnering with the applicable local jurisdiction(s)’ designated primary ambulance
service(s) that wishes to apply for a Certificate of Approval to operate a Mobile
Integrated Health Care (MIH) Program with Emergency Department (ED)
Avoidance component in Massachusetts. Please submit a completed MIH Program
application with this application, or if the program already has an MIH Program
approval (including responses relevant for ED Avoidance component), please
submit a copy of the Certificate of Approval with this application. If seeking a
Certificate of Approval for an MIH Program without an ED Avoidance component,
the applicant must submit a separate MIH Program application, with all required
attachments, responses, and MIH Program 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
they relate.
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-with-ed-avoidance.
2
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.
REGULATIONS
For complete information regarding approval of an MIH Program, please
refer to 105 CMR173.000 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 with ED Avoidance
Component application process, please contact the MIH Program
at 617-753-8484 or MIH@state.ma.us.
APPLICATION ATTACHMENT CHECKLIST
Either (1) completed MIH Program Application or (2) Certificate of Approval for an
already approved MIH Program. Note: The “Gap in service delivery narrative” in the
MIH Program Application must be specific to the ED Avoidance Program.
MIH Program Application Number or Approval Number: _________________
This application (MIH with ED Avoidance Component Application)
If applicable, list of ESP partners and description of how program will address patients
with behavioral health needs
Affiliate hospital medical director(s’) contact name, email address, and title
Executive summary (2.a.)
911 to MIH ED Avoidance transition description (3.a.)
Policies and procedures (3.b.)
Clinical and triage protocols (4.a.)
Training curriculum (4.b.)
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
Previous 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 ID found on the last page of the application.
3
* Date:
* Street
* City * Zip Code
* Name of Contact
Person:
* Telephone Number:
* Program Funding:
Agency funds Grant support 3
rd
party payers
Ambulance License Number
A
m
bulance Contact Name and Title
Ambulance Telephone Number
Ambulance
E-Mail Address
1. APPLICANT INFORMATION
* State
* Title:
* Email Address:
* Title:
* Email Address:
Signature of Authorized
Signatory:
*
* Date:
Tax revenue Other (describe):_________________________
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.
* Address of Applicant
Organization:
* Name of Applicant
Organization:
* Name of Medical Director:
* Telephone Number:
*
Name of Authorized
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-with-ed-avoidance
(name by which you will conduct business)
Applicable Local Jurisdiction(s)
Primary Ambulance Service
For each jurisdiction covered by the proposed program, the primary ambulance service must
be
included. Please include the following information for the ambulance service included in the
proposed program. Please attach a document including the contact name, email address,
and title for each affiliate hospital medical director.
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4
Please list all health car
e 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
Proposed Operational Partner
Contact Last Name,
First Name
Email Address
Attestation:
In accordance with 105 CMR 173.000, the undersigned hereby applies for
designation to establish a Mobile Integrated Health Care Program with ED
Avoidance as set forth under provisions of 105 CMR 173.000.
The undersigned representative(s) of the provider 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 with ED Avoidance to comply with 105 CMR 173.000, the applying
organization understands and acknowledges 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.
__________________________
Signature of Authorized Signatory
Date Signed
__________________________________________________________________
Print Name of Authorized Signatory
__________________________________________________________________
Title of Authorized Signatory
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signature
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5
__________________________
Signature of Medical Director
Date Signed
__________________________________________________________________
Print Name of Medical Director
__________________________________________________________________
Title of Medical Director
2. PROPOSED ED AVOIDANCE SERVICES
a. Please attach an executive summary describing the ED Avoidance services
that the proposed program intends to provide, including patient population(s) and
jurisdiction(s), and how this/these service(s) relate to the MIH Program
Application gap in service delivery narrative.
b. I attest that the program has documentation of appropriate clinical and triage
protocols and advanced training for paramedics who will practice ED Avoidance
programming.
__________________________
________________________
Signature of Authorized Signatory
Date S
igned
_____________________________________________________________________
Print Name of Authorized Signatory
_____________________________________________________________________
Title of Authorized Signatory
3. 911 TO MIH ED AVOIDANCE TRANSITION
a. Please attach a description of how the proposed program will coordinate and
manage the transfer of care from a 911 EMS patient to a MIH patient, for the
appropriate cases in which the responding designated primary ambulance service’s
paramedic assesses the EMS patient, consults with online medical direction, and
determines that the patient may be more appropriately managed as an MIH patient,
in accordance with Mobile Integrated Health Program with an ED Avoidance
Component Protocol for Determination to Treat/Transport to Alternate Destination.
Note that patient refusal to be transported and written consent to be treated as an
MIH patient must be obtained by the MIH ED Avoidance personnel. Please explain
how the program will track, document, and perform continuous quality improvement
on calls in which there is a transition from a 911 episode of care to a MIH treatment.
Include an explanation on how your MIH with ED Avoidance Component Program
will follow the process for timely coordination with a patient’s primary care provider,
or associated health care entity to establish a primary care relationship.
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signature
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6
b. Please attach a copy of the proposed program’s policies and procedures
demonstrating how a patient's informed consent will be obtained. Policies and
procedures must specifically outline how:
I. written refusal to transport will be obtained;
II. written consent will be obtained for a patient to be treated as an MIH
patient;
III. refusal and consent will occur after speaking with Medical Direction and in
accordance with Mobile Integrated Health Program with an ED Avoidance
Component Protocol for Determination to Treat/Transport to Alternate
Destination.
c. Please attach an attestestation 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 during a MIH with ED Avoidance Component encounter.
a. Please attach clinical and triage protocols that will be used as part of your
proposed ED Avoidance service(s).
b. Please attach a description of advanced training plans including the curriculum
that will be utilized to train EMS Personnel who will support the proposed MIH
Program with ED Avoidance component. Please include in the curriculum a
description of how the competencies of trained resources will be demonstrated
and assessed.
4. ATTACHMENTS
7
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 Eda Application Form Updated (Commonwealth of Massachusetts)

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Completed 22 July 2020

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