Adult Ambulatory Core Components and Milestones: Justice Area of Concentration

Below are the Core Components and Milestone documents for the Justice Area of Concentration. The documents provide a summary of due dates for Milestones, detailed descriptions of Core Components, and a list of resources to help you complete Milestones.

TI Program Year 6 Core Components and Milestones

Justice Year 6 Measures and Milestones

TI Program Year 4 & 5 Core Components and Milestones

TIP Justice QIC Recording, March 16, 2021

TIP Justice QIC Recording, December 15, 2020

TI Justice Update Meeting Recording, September 10, 2020

Adult Ambulatory: Justice Core Components-Year 2 and 3

Adult Ambulatory: Criminal Justice Core Components

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

TI Justice Forum Presentation, July 30, 2018

Billing for Targeted Investments Justice Participants

TIP Justice Clinic Locations

Download TIP Justice Clinic Locations Map as PDF

TIP Justice Clinic Locations Map