CHW Referral – Families Matter of RI

Practice Name *

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LPHA Provider

NPI number

Patient Name *

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DOB

Patient Address

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Please add Client diagnosis below

Behavioral Health Diagnosis

Medical Diagnosis

Health Risk Diagnoses

Check all that apply: CHW services are considered medically necessary only when provided to a Medicaid beneficiary who meets at least one (1) of the following criteria: Medical necessity refers to medical, surgical, or other services required for the prevention, diagnosis, cure, or treatment of an injury, health-related condition, disease, or its symptoms

Goals for Patient: Please select one or all three of the goals for each identified task by marking them, along with a client diagnosis to be addressed.

Please pain Medical

Effective July 1, 2025 Rhode Island Medicaid laws state that all CHW referrals must be made by a RI licensed professional and must include a provider’s NPI number by the Ordering/Referring Provider. This means that your NPI will be included in the CHW claim as the referring provider for this referral. The need for Medicaid CHW services must be substantiated through documented and objective health indicators, including but not limited to Behavioral Health, Medical Diagnosis, and Health Risk Diagnoses.

GOAL DEFINITIONS: On the front page please select the goals you would like your patient/Client to work on.

Health Promotion and Coaching: One on one face to face in person activities that involve is tied to a diagnosed health condition

a) Chronic Condition Management Support: Supporting beneficiary in managing a chronic condition reinforcing self-goals aligned with clinical care plans.
b) Motivational Interviewing and Goal Setting: Using motivational interviewing to help a beneficiary identify barriers and commit to health-related behavior change; using short- and long-term health goal setting.
c) Evidence-Based Health Coaching (Not Health Education): Delivering personalized health coaching using pre-approved evidence-based techniques and standardized materials.
d) Health Action Planning and Tracking: Helping beneficiary set and track action plans for health improvement (e.g., quitting smoking, improving diet).
e) Condition-Linked Lifestyle Change Support: Discussing lifestyle modifications linked to diagnosed conditions
f) Post Hospitalization Coaching: Assisting in implementing discharge plans to avoid hospital readmission.
g) Medication Support Education (Non-Clinical): Reinforcing medication adherence by assisting beneficiary with understanding prescribed medication regimens and developing strategies for compliance.
h) Behavioral Health Self-Management Tools (Non-Clinical): Teaching behavioral health self-management techniques.
i) Cultural and Linguistic Health Coaching: Using culturally and linguistically appropriate methods to reduce health disparities.

Health Education and Training: provided one-on-one or in small groups in person aim to prevent/reduced disease, reduce disability, or promote health maintenance:

a) Chronic Disease Prevention and Self-Management: Providing education to help beneficiary recognize symptoms, manage medications, and implement lifestyle changes related to chronic conditions.
b) Tobacco and Substance Use Reduction: Educate beneficiary on strategies to reduce or quit tobacco or substance use. May include motivational interviewing, harm reduction, or connections to cessation and behavioral health programs.
c) Nutrition and Physical Activity Education (Non-Clinical): Basic health education, nutrition and exercises and movement for wellness or chronic condition management. (E.g., reading nutrition labels, walking basics).
d) Family Planning and Prenatal Risk Reduction: Educate on safe sexual health practices, birth control options, and prenatal health to support maternal and child health and reduce high-risk behaviors during pregnancy.
e) Injury Prevention and Environmental Health Risks: Providing education about reducing risk of injury (e.g., falls), occupational health hazards, and environmental health concerns such as lead, mold, or air pollution.
f) Preventative Health Promotion: Teaching about the importance of preventive screenings and connect to screening services.
g) Medication Adherence Support: Educating beneficiary on prescribed medication use and adherence.
h) Post-Hospitalization Literacy Support: Helping beneficiary understand discharge paperwork or follow-up care plans.
i) Trauma and Health Education: Basic information tied to clinical treatment plans (e.g., trauma and chronic disease link) aligned with the care plan and medical necessity documentation.

Health System Navigation and Resource Coordination: Navigation and Resource Coordination involves one-on-one support to navigate resource Coordination in-person or via telehealth option

a) Connecting Beneficiaries to Medicaid Covered Services: Providing support to help the beneficiary identify and establish care with a Medicaid-enrolled primary care provider (PCP) or specialist.
b) Assisting with Appointment Scheduling and Preparation: Scheduling and preparing for medical appointments—helping the beneficiary schedule appointments for Medicaid-covered services
c) Medical Transportation: Helping the beneficiary navigate the process of arranging rides through the Non-Emergency Medical Transportation (NEMT) broker or giving clear directions for how to reach a service location.
d) Assisting with Telehealth Use and Technology Navigation: Helping the beneficiary understand how to use telehealth platforms and supporting participation in virtual care visits when appropriate.
e) Facilitating Referrals to Social and Community Supports: Helping the beneficiary connect to community-based or social service organizations, such as housing programs, food access, or behavioral health supports as described in order from the LPHA.
f) Support for Re-Engagement in Care: Re-engaging beneficiaries who have been disengaged from healthcare.