The Department covers the services in §§B—G of this regulation when these services have been documented, pursuant to the requirements in this chapter, as necessary. Comprehensive Care Management. The health home shall collaborate to provide comprehensive care management services including: An initial assessment performed prior to the patient's enrollment, which includes: A comprehensive assessment of the participant's physical health, mental health, chemical dependency, and social service needs, signed off on by a physician or nurse practitioner, if no such assessment has been performed in the preceding 6-month period; and Requesting records from the participant's primary care physician and other providers; Development of a care plan within 30 days following enrollment, in accordance with Regulation .04J(3) of this chapter; Delineation of roles, which includes: Assigning each staff member clear roles and responsibilities; and Ensuring that participant care plans identify providers and specialists involved in the participant's care; and Monitoring and reassessment, which includes: Monitoring and documenting participant health status and progress toward care plan goals; Monitoring population health status and service use to determine adherence to or variance from treatment guidelines; and Outcomes evaluation and reporting, which includes using eMedicaid and other available HIT tools such as electronic health records. Care Coordination and Health Promotion. The health home shall coordinate and provide access to: High-quality health care services; Preventive and health promotion services, including education regarding: Mental illness; Substance use disorders; and Chronic physical health conditions; Mental health and substance abuse services; Chronic disease management services; and Long-term care supports and services. The health home shall coordinate services and support, including: Appointment scheduling; Referrals and follow-up monitoring; Hospital discharge processes; and Communication with other providers and supports, including school service providers. The health home shall assign each participant a health home care manager who is responsible for coordinating the participant's care and ensuring implementation of the care plan. The health home shall develop policies and procedures to facilitate collaboration between primary care, specialist, and behavioral health providers, community-based organizations, and, for minors, school-based providers. The health home shall follow security protocols to protect confidential health information. The health home shall assist participants with the implementation of their care plan, including: Health education specific to a participant's chronic conditions; Development of a plan for self-management; Medication review and education; and Substance use prevention, smoking cessation, obesity reduction, improved nutrition, and increased physical activity. A health home serving minors shall actively involve parents and families in providing services in accordance with §C(6) of this regulation, including: Identifying conditions for which the minor may be at risk due to family, physical, or social factors; and Working with the minor and parents and families to address the identified conditions. The health home shall use the ASO system to document, review, and report health promotion services delivered to each participant. Comprehensive Transitional Care. The health home shall provide services designed to: Streamline plans of care; Reduce avoidable hospital admissions; Ease the transition to long-term services; Interrupt patterns of frequent hospital emergency department use; and Ensure timely and proper follow-up care across settings, including from: An acute care setting to other settings; and A pediatric system of care to an adult system of care. The health home shall increase participants' and caregivers' ability to manage care and live safely in the community. The health home shall utilize CRISP to receive alerts of hospital admissions, discharges, or transfers among their health home participants. The health home shall follow up with participants within 2 business days of discharge with a home visit, phone call, or scheduling an on-site appointment. Individual and Family Support Services. Services shall include, but are not limited to: Advocating for individuals and families; Supporting participants in obtaining and adhering to medications and other prescribed treatments; Accessing resources that support participants, including providing referrals for: Community services; Social support services; Recovery services; and Transportation to medically necessary services; Improving participants' health literacy; Increasing the participant's ability to self-manage care; Facilitating participation in the ongoing revision of the treatment plan; and Providing information on advance directives and health care power of attorney. The health home shall utilize peer supports, support groups, and self-care programs to: Increase participants' and caregivers' knowledge of the participants' diseases; Increase caregivers' care-management capabilities; Promote participants' adherence to their plan of care; and Increase participants' self-management capabilities. The health home shall ensure that all communication shared with the participant, the participant's family, and caregivers is language, literacy, and culturally appropriate. Referral to Community and Social Support Services. The health home shall provide assistance in accessing and coordinating, as appropriate: Medical assistance; Disability benefits; Subsidized or supported housing; Personal needs support; Peer support; or Legal services. The health home shall assist in coordinating these services. Use of HIT to Link Services. The provider shall use HIT, including CRISP and the ASO system to: Facilitate communication between health home staff members, the participant, and their caregivers; and As appropriate, provide feedback to participants' other providers. Health home services provided by PRP, MTS, or OTP staff qualify as covered services.