1 Enter the name of the facility in which you are completing this survey for.
* must provide value
2 What is your name?
* must provide value
3 What is your job title?
* must provide value
4 What is your professional email?
* must provide value
5 Select the button that describes how familiar you are with the Justice-Involved Re-entry Initiative (choose one).
* must provide value
Very familiar (Comfortable with requirements, expectations, and services to be provided)
Familiar (Knowledgeable of project, unsure of implementation steps)
Unfamiliar (Heard of project, need more information for implementation)
Never heard of project
Very familiar (Comfortable with requirements, expectations, and services to be provided)
Familiar (Knowledgeable of project, unsure of implementation steps)
Unfamiliar (Heard of project, need more information for implementation)
Never heard of project
6 Based on data from the past 6 months, what is the average number of post-adjudicated individuals that are released from incarceration during each month?
* must provide value
7 Does your facility currently have a policy or procedure to screen individuals for active Medicaid enrollment at intake or booking?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
7a Briefly describe the process. (When process takes place, facility specific details, etc.)
* must provide value
7b What date will this action plan be implemented?
* must provide value
8 If individuals are not currently enrolled in Utah Medicaid, does your facility currently have a process or procedure to help individuals apply and maintain enrollment for Medicaid at the time of booking or intake?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
8a Briefly describe the process. (When process takes place, facility specific details, etc.)
* must provide value
8b What date will this action plan be implemented?
* must provide value
8c Does this process or procedure include steps to make sure that all individuals receive the mailed notices from Department of Health and Human Services (DHHS) and Department of Workforce Services (DWS) including, but not limited to, Medicaid determinations, Fair Hearing Request Forms, MCO correspondence, and case correspondence?
* must provide value
Yes
No
9 Does your facility have data sharing agreements and/or a procedure to share data with the Department of Workforce Services (DWS), about incarcerated individuals intake and release dates, as well as identifying information?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
9a Briefly describe the process. (When process takes place, facility specific details, etc.)
* must provide value
9b What date will this action plan be implemented?
* must provide value
10 Does your facility have data sharing agreements and/or a procedure to share data with pre-release case managers including incarceration intake and release dates (if using external case managers)?
* must provide value
Yes
No
Action plan to implement
N/A
Yes
No
Action plan to implement
N/A
10a What date will this action plan be implemented?
* must provide value
10b Briefly describe the agreements.
11 Does your facility have data sharing agreements and/or a procedure to share data with community-based providers and/or Utah Medicaid managed care plans?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
11a What date will this action plan be implemented?
* must provide value
11b Briefly describe the agreements.
12 Is your facility currently enrolled in the Medicaid claims payment system, PRISM and able to submit claims and report services?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
12a What date will this action plan be implemented?
* must provide value
13 Are your facility's contracted health providers currently enrolled in PRISM as approved Medicaid providers and able to submit claims and report services?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
13a What date will this action plan be implemented?
* must provide value
14 Does your facility deliver medication-assisted treatment (MAT) for substance use disorders when clinically appropriate?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
14a Briefly describe what type of treatment is provided, including medication and counseling.
* must provide value
14b What date will this action plan be implemented?
* must provide value
15 Does your facility have a documented procedure to deliver physical and behavioral health clinical services to diagnose health conditions, provide treatment, and support the pre-release case manager's development of a treatment plan?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
15a Briefly describe this procedure or process.
* must provide value
15b What date will this action plan be implemented?
* must provide value
16 Does your facility have a documented procedure to provide laboratory or radiology services?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
16a What date will this action plan be implemented?
* must provide value
17 Can your facility support scheduling and providing the space needed for provider services, such as case management, clinical consultation, or community health workers (including physical space for in-person services, and/or space and technology for virtual visits)?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
17a Briefly describe this procedure or process.
* must provide value
17b What date will this process/procedure be implemented?
* must provide value
18 Does your facility have infrastructure and a process to distribute all medications covered under Utah Medicaid medication benefit?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
18a Briefly describe this procedure or process.
* must provide value
18b What date will this process/procedure be implemented?
* must provide value
19 Does your facility currently provide a 30-day supply of prescription medications or over the counter drugs immediately upon release?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
19a Does this include a 30-day prescription refill?
* must provide value
Yes
No
19b What date will this action plan be implemented?
* must provide value
20 Does your facility have infrastructure and a process in place for the distribution of Durable Medical Equipment (DME) on the day of release?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
20a Briefly describe this procedure or process.
* must provide value
20b What date will this process/procedure be implemented?
* must provide value
21 Does your facility have a policy and process to assess an individual's needs for behavioral and physical health services, including an evaluation of needs post-release and the ability to create a person centered care plan to address all identified needs?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
21a Briefly describe this procedure or process.
* must provide value
21b What date will this process/procedure be implemented?
* must provide value
22 Does your facility have a policy and process to assess an individual's needs for behavioral and physical health services, including, completing required medical releases and consents to release information to relevant parties, such as assigned case managers and community providers?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
22a Briefly describe this procedure or process.
* must provide value
22b What date will this process/procedure be implemented?
* must provide value
22c Do these assessments cover the Health Related Social Needs, Long Term Services and Supports, and overall Social Determinants of Health?
* must provide value
Yes
No
23 Are individuals currently assigned a case manager in your facility?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
23a How many days prior to release are the case managers assigned?
* must provide value
23b What date will this action plan be implemented?
* must provide value
24 Does your facility have a process to support case managers in creating a final re-entry care plan that is shared with the member, correctional facility clinical care team, post-release providers, managed care plan, and community-based case managers supporting the Social Determinants of Health?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
24a Briefly describe this process or procedure.
* must provide value
24b Does this procedure cover the completion of consent release forms?
* must provide value
Yes
No
24c What date will this process/procedure be implemented?
* must provide value
24d Are case managers creating a care plan that assesses and addresses both pre- and post-release needs, an individual's physical and behavioral health needs, including but not limited to, Health Related Social Needs (HRSN), Long Term Services & Supports (LTSS), and the Social Determinants of Health (SDOH)?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
24e Does the assistance provided by pre-release case manager include providing incarcerated members assistance in maintaining Medicaid enrollment, including but not limited to, providing verifications or information, completing renewal or recertification procedures, and completing any Fair Hearing documents or procedures?
* must provide value
Yes
No
24f What date will this action plan be implemented?
* must provide value
25 Does your facility have a process or procedure for a "warm handoff" between the case manager and post-release providers and case management team like managed care plan care managers?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
25a Briefly describe this process or procedure.
* must provide value
25b What date will this process/procedure be implemented?
* must provide value
25c Does this procedure for "warm handoffs" include linkages for behavioral and physical health providers?
* must provide value
Yes
No
26 Does your facility have a functioning Electronic Health Record (EHR) system that can record and coordinate services between physical and behavioral health providers?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
26a What date will EHR be implemented?
* must provide value
26b Does this EHR capture diagnostic billing codes while using ICD-10 codes?
* must provide value
Yes
No
27 Are your facility case managers internal or external providers?
* must provide value
Embedded
External
Other
27a Briefly describe 'Other'.
* must provide value
28 Does your facility have a governance structure for coordinating with key partners including, DHHS, DWS, case management organizations, community-based organizations, and managed care providers?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
28a What is the proposed date for implementation?
* must provide value
29 Does your facility have a documented process to collect, monitor, and report to DHHS required measures including corrective action processes to address operational challenges?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
29a Briefly describe the process or procedure.
* must provide value
29b What is the proposed date for implementation?
* must provide value
30 Does your facility have a documented policy and process to assist individuals submit Medicaid renewals, change reports, or other verifications and information required to DWS, while still incarcerated?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
30a Briefly describe the process or procedure.
* must provide value
30b What is the proposed date for implementation?
* must provide value
31 Does your facility have a documented policy and procedure for the data exchange necessary for care coordination and transition activities?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
31a Briefly describe the process or procedure.
* must provide value
31b What is the proposed date for implementation?
* must provide value
32 Does your facility have a policy and procedure to ensure that only licensed, registered, certified, or otherwise appropriately credentialed or recognized practitioners will provide services within their individual scope of practice and, as applicable, receive supervision required under their scope of practice laws?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
32a Briefly describe this policy and procedure.
* must provide value
32b What is the proposed date for implementation?
* must provide value
32c Does this policy and procedure verify that all providers are enrolled as Medicaid providers?
* must provide value
Yes
No
33 Does your facility have a policy and procedure that defines which services are delivered by community-based organizations versus correctional facility-based providers?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
33a Briefly describe this policy and procedure.
* must provide value
33b What is the proposed date for implementation?
* must provide value
34 Does your facility currently have staffing and/or contractor structure to support each readiness element and compliance with DHHS requirements for Utah Medicaid Justice Involved Re-entry Services?
* must provide value
Yes
No
Action plan to implement
Yes
No
Action plan to implement
34a Detail where you do not have the required staffing support.
* must provide value
34b What is the proposed date for staffing readiness?
* must provide value
35 What resources (type and amount) are needed in order for your facility to become operational?
36 What other questions does your facility have?
37 What feedback or information would you like to share with Utah Medicaid?
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