American Innovative American Innovative Healthcare Solutions Healthcare Solutions

Psychiatric CarePsychiatric Care

Service Expansion ProposalService Expansion Proposal

For long Term CareFor long Term Care

Presentation OverviewPresentation Overview Who is American Who is American

Innovative Solutions? Innovative Solutions? 3-53-5

Continuum of Care. 6Continuum of Care. 6 Advantages for Advantages for

Members. 10Members. 10 Advantages to Advantages to

Community Provider. Community Provider. 1111

Levels of Care 12-13Levels of Care 12-13

Professional Professional Disciplines. 14Disciplines. 14

Licensed Clinician Licensed Clinician Functions. 15Functions. 15

Medicare Specifics Medicare Specifics 16-2016-20

Shared Casework Shared Casework Functions. 21Functions. 21

Next Steps. 22Next Steps. 22 Contact Information. Contact Information.

2323

2

ValuesValues

CompassionCompassion ExcellenceExcellence PartnershipPartnership InnovationInnovation

3

Principles of our Principles of our PhilosophyPhilosophy

Social responsibility to help Social responsibility to help underserved.underserved.

Respect and dignity.Respect and dignity. Collaboration.Collaboration. Concern for the whole person.Concern for the whole person. Address clinical, business, corporate Address clinical, business, corporate

and social-ethical issues.and social-ethical issues.

4

Cost Effectiveness comes Cost Effectiveness comes from:from:

Removing obstacles to help patients.Removing obstacles to help patients. Rapid Innovation/anticipation of regulatory Rapid Innovation/anticipation of regulatory

changes.changes. Innovative integration of clinical and billing Innovative integration of clinical and billing

services. services. Optimizing full time equivalent staff.Optimizing full time equivalent staff. Using Contractors to expand services.Using Contractors to expand services. Matching skill levels of staff to case mix.Matching skill levels of staff to case mix. Continuous Quality Improvement.Continuous Quality Improvement. Using Using ““ExpertsExperts”” for training. for training. Optimizes resources Optimizes resources

of talent and time toward measurable training goals.of talent and time toward measurable training goals.5

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Developing a Continuum of Care

Targeted PopulationsTargeted PopulationsAdultsAdults

Inpatient Inpatient Readmissions <30 Readmissions <30 daysdays

Medicare FundedMedicare Funded Chronically Mentally Chronically Mentally

Ill.Ill. Mentally ill people Mentally ill people

living in extended living in extended care facilities.care facilities.

Mentally ill living in Mentally ill living in group homes, shared group homes, shared apartments.apartments.

Newly Diagnosed Newly Diagnosed conditions.conditions.

Mental status Mental status changes.changes.

General functioning General functioning between 35-70 on between 35-70 on the Global the Global Assessment of Assessment of Functioning scale.Functioning scale.

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Who We Are and Are NotWho We Are and Are NotAdultsAdults

We Are:We Are: Innovative medical Innovative medical

management company.management company. Serving Mentally ill patients Serving Mentally ill patients

living in nursing homes.living in nursing homes. Serving patients from the Serving patients from the

Subpart S group requiring a Subpart S group requiring a higher level of psychiatric higher level of psychiatric care.care.

Serving Mentally ill patients Serving Mentally ill patients living in group homes, living in group homes, shared apartments.shared apartments.

Serving Newly Diagnosed Serving Newly Diagnosed conditions.conditions. Due to mental status Due to mental status

changeschanges Changes in PlacementChanges in Placement

We Are Developing:We Are Developing:

Partnership on Illinois Partnership on Illinois Subpart S services.Subpart S services.

Linkage to Inpatient Linkage to Inpatient Care providers.Care providers.

A Partial Hospital A Partial Hospital Provider.Provider.

Linkage with Linkage with Psychosocial Psychosocial Rehabilitation Rehabilitation Providers.Providers.

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What We Learned/Where We Are What We Learned/Where We Are GoingGoing

What We have LearnedWhat We have Learned

There are many There are many underserved Mentally underserved Mentally Ill Ill people.people.

Day Programs are not Day Programs are not sustainable.sustainable.

IL HFS and Medicaid are IL HFS and Medicaid are too unstable to build a too unstable to build a service delivery continuum. service delivery continuum.

Medicare provides stable Medicare provides stable income through 2014 income through 2014 through Mental Health through Mental Health Parity.Parity.

We are DevelopingWe are Developing

A continuum of sustainable A continuum of sustainable services.services.

Partnerships with Nursing Partnerships with Nursing Home owners.Home owners.

Replication of Services in Replication of Services in Wisconsin.Wisconsin.

Developing linkage to Developing linkage to Inpatient Care providers.Inpatient Care providers.

Linkages to Partial Hospital Linkages to Partial Hospital Programs.Programs.

Linkages to Intensive Linkages to Intensive Outpatient Programs.Outpatient Programs.

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Advantages for MembersAdvantages for Members Members receive Members receive

excellent patient care.excellent patient care. No out of pocket cost.No out of pocket cost. We process and store We process and store

patient charts.patient charts. We document their We document their

ongoing needs or ongoing needs or disability.disability.

We assist in audit or We assist in audit or accreditation accreditation preparation.preparation.

We provide treatment We provide treatment with IL. Licensed with IL. Licensed Clinicians.Clinicians.

We are able to use some We are able to use some existing employees.existing employees.

PROFESSIONAL PROFESSIONAL MANAGEMENT OF: MANAGEMENT OF:

Treatment Planning.Treatment Planning. Integration of care.Integration of care. Billing and revenue Billing and revenue

collection.collection. CMS Psychiatric care CMS Psychiatric care

changes.changes.

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Advantages for Community Advantages for Community ProviderProvider

We assess and/or treat more challenging behaviors.We assess and/or treat more challenging behaviors. We treat patients on site or where members live.We treat patients on site or where members live. We provide assessments and treatment under We provide assessments and treatment under

Medicare standards.Medicare standards. We bring an additional revenue stream to fund We bring an additional revenue stream to fund

care.care. We assist in audit or accreditation preparation.We assist in audit or accreditation preparation. Patient documentation may qualify patients for Patient documentation may qualify patients for

additional reimbursement.additional reimbursement. We recruit, hire, train and supervise, Illinois We recruit, hire, train and supervise, Illinois

Clinically Licensed professionals.Clinically Licensed professionals.

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Psychiatric Levels of CarePsychiatric Levels of CareProblemsProblems and Servicesand Services

ProblemsProblems GAFGAF Appropriate ServicesAppropriate Services

InpatientInpatient Severe uncontrolled Severe uncontrolled delusions, delusions, hallucinations, suicidal hallucinations, suicidal plans or attempts.plans or attempts.

110-300-30Medication management, crisis Medication management, crisis stabilization, referral to outpatient stabilization, referral to outpatient resources, including housing and 24 X resources, including housing and 24 X 7 supervision.7 supervision.

Partial Partial HospitalizationHospitalization

Moderate-Severe Moderate-Severe delusions, delusions, hallucinations, suicidal hallucinations, suicidal thoughts without thoughts without plans.plans.

25-4025-40Medication optimization, group Medication optimization, group Therapy, Psychological education, Therapy, Psychological education, Med. Ed., Individual therapy and Med. Ed., Individual therapy and referrals to outpatient resources referrals to outpatient resources made.made.

Intensive Intensive OutpatientOutpatient

Mild-moderate, Mild-moderate, Delusions, Delusions, hallucinations, hallucinations, decreasing suicidal decreasing suicidal thoughts without thoughts without plans.plans.

41-6041-60Group Therapy, psychological Group Therapy, psychological education, Individual therapy has education, Individual therapy has begun with an individual therapist and begun with an individual therapist and psychiatrist. Linkage to outpatient psychiatrist. Linkage to outpatient resources completed.resources completed.

Outpatient Outpatient Medically Necessary CareMedically Necessary Care

Reasonable Probability to Reasonable Probability to Benefit.Benefit.

Mild-moderate, Mild-moderate, Delusions, Delusions, hallucinations, hallucinations, decreasing suicidal decreasing suicidal thoughts without thoughts without plans.plans.

35-7035-70Group Therapy. Individual therapy has Group Therapy. Individual therapy has begun with an individual therapist and begun with an individual therapist and psychiatrist. Evaluation and psychiatrist. Evaluation and Management. Medication Management. Medication management.management.

Psychosocial Psychosocial Rehabilitation Rehabilitation No No medical necessity for medical necessity for group or individual group or individual therapy.therapy.

Moderate-Severe Moderate-Severe delusions, delusions, hallucinations, without hallucinations, without suicidal plans.suicidal plans.

10-5010-50Assistance with most activities of Assistance with most activities of daily living, group social, recreational daily living, group social, recreational activity. Medication compliance, activity. Medication compliance, teaching social interaction skills, Med. teaching social interaction skills, Med. Ed., Ed.,

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Psychiatric and Addictions Levels of Psychiatric and Addictions Levels of CareCare

Levels of Care BehaviorsBehaviors

Global Global Assessment Assessment of of Functioning Functioning (GAF) Axis V(GAF) Axis V

Hours per Hours per weekweek

What is Medically What is Medically Necessary & Necessary & Reasonable? Reasonable?

Appropriate Appropriate ServicesServices

InpatientInpatient Hallucinations, Hallucinations, delusions, delusions, suicidalsuicidal

GAF 10-30GAF 10-30

24 X 7 care24 X 7 careEmergency Emergency management, management, Stabilization. Stabilization. Medication changesMedication changes

Individual, family, Individual, family, group tx, medication group tx, medication Ed., OTEd., OT

Partial Partial HospitalizationHospitalization

Impairment in Impairment in reality testing reality testing and and communicationcommunication

GAF 25-40GAF 25-40

16-20 hours 16-20 hours per weekper week

Increase family Increase family support, teach coping support, teach coping skills, optimize meds.skills, optimize meds.

Individual, family, Individual, family, group tx, group tx, psychological psychological education, education, medication Ed., OTmedication Ed., OT

Intensive Intensive Outpatient (Not Outpatient (Not recognized by recognized by Medicare)Medicare)

Moderate Moderate symptoms, symptoms, and difficulty and difficulty in working and in working and social social functioningfunctioning

GAF 50-70GAF 50-70

10-20 hours 10-20 hours per weekper week

Expand support Expand support system, demonstrate system, demonstrate effective coping skills, effective coping skills, return to work or return to work or school.school.

Psych Assessment, Psych Assessment, psychological psychological education, Group, education, Group, individual and family individual and family therapy.therapy.

OutpatientOutpatient Mild-severe Mild-severe symptoms.symptoms.

35-7035-70

1-10 hours 1-10 hours per weekper week

Talk therapy, medical Talk therapy, medical management, management, reassessment every reassessment every 30-90 days.30-90 days.

Psych Assessment, Psych Assessment, Group, individual and Group, individual and family therapyfamily therapy

Psychosocial Psychosocial RehabilitationRehabilitation

Low probability Low probability to improveto improve

Reached their Reached their baseline of baseline of functioningfunctioning

Activities Daily Living, Activities Daily Living, recreation, social recreation, social activity, med. activity, med. compliancecompliance

Support, counseling, Support, counseling, employment to employment to maintain baseline.maintain baseline.

LCPC

LCSW

Behavioral Health

AssistantsM.D.

Senior Leadership

Professional Disciplines

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Psychiatrists

Licensed Clinicians Licensed Clinicians FunctionsFunctions

Complete Assessments Complete Assessments (Differential Diagnosis)(Differential Diagnosis)

Appropriate level of Appropriate level of care determination with care determination with medical necessity.medical necessity.

Authorize Treatment Authorize Treatment Plans.Plans.

Collaborate with Collaborate with primary care primary care physicians.physicians.

Provide individual Provide individual therapy.therapy.

Use critical thinking to:Use critical thinking to:

Compare treatment plan to Compare treatment plan to efficacy based practices.efficacy based practices.

Function in a Function in a collaborative and collaborative and supportive role with:supportive role with: the case worker.the case worker. Other Clinically Other Clinically

Licensed staff.Licensed staff. Behavioral Health Behavioral Health

Assistants.Assistants.

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~ 16 ~

Psychological Services Psychological Services under the Incident-to under the Incident-to

Provision Provision WPS PSYCH-013-014WPS PSYCH-013-014

~ 17 ~

List of “Qualified List of “Qualified Individuals”Individuals”

IllinoisIllinois

Only the following types of individuals, … are Only the following types of individuals, … are qualified to perform the indicated diagnostic and/or qualified to perform the indicated diagnostic and/or therapeutic psychological services under the therapeutic psychological services under the "incident to" provision:"incident to" provision:

Psychiatrist, Psychiatrist, LCSWLCSW Licensed Clinical Social Worker, Licensed Clinical Social Worker, MSNMSN psychiatrically trained, master’s level psychiatrically trained, master’s level LCPCLCPC Licensed Clinical Professional Counselors, doctoral Licensed Clinical Professional Counselors, doctoral level Licensed clinical psychologist, level Licensed clinical psychologist, CPCP..

Qualified providers must meet both the Qualified providers must meet both the educational and licensing criteria listed in PSYCH-educational and licensing criteria listed in PSYCH-002. This includes Illinois requirement for 002. This includes Illinois requirement for independent practice.independent practice.

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Professional CredentialingProfessional Credentialing

Billing provider can only hire and Billing provider can only hire and supervise a professional whose scope of supervise a professional whose scope of practice is within their own scope of practice is within their own scope of practice practice Example: Certified nurse midwife may Example: Certified nurse midwife may

not hire a CP and bill for that CP’s not hire a CP and bill for that CP’s services under the incident-to provisionservices under the incident-to provision

~ 19 ~

Professional Credentialing Professional Credentialing

Psychological services may be Psychological services may be delegated only to employees who delegated only to employees who qualify to perform the service.qualify to perform the service.

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Coding Guidelines for Incident-Coding Guidelines for Incident-toto

Any ICD-9 code submitted must have Any ICD-9 code submitted must have medical justification in the medical medical justification in the medical record for establishing that diagnosisrecord for establishing that diagnosis If medical record is lacking such If medical record is lacking such

justification, a retroactive denial and justification, a retroactive denial and recoupement may be made.recoupement may be made.

Shared Case Work FunctionsShared Case Work Functions

Implementation of Implementation of treatment plan. treatment plan.

Daily record review Daily record review and assessment of and assessment of patientpatient’’s progress.s progress.

Validate that medical Validate that medical record accurately record accurately reflects patientreflects patient’’s s current condition.current condition.

Coordinate/facilitate Coordinate/facilitate communication communication among team among team members, and other members, and other providers.providers.

Use critical thinking Use critical thinking to:to: Remove obstacles.Remove obstacles. Compare treatment Compare treatment

plan to services plan to services received.received.

Function in a Function in a collaborative and collaborative and supportive role with: supportive role with: Primary Care Primary Care

Physician.Physician. Facility social service Facility social service

staff.staff. Psychiatrists.Psychiatrists.

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Next StepsNext Steps

Completion of AIHS Management Completion of AIHS Management Services Agreement.Services Agreement.

Start Up Plan Development.Start Up Plan Development. Interactive Orientation to policies, Interactive Orientation to policies,

procedures and documentation.procedures and documentation. Physician Referral for Services. Physician Referral for Services. Individualized Patient Care is Matched Individualized Patient Care is Matched

to Patient Choice and Availability.to Patient Choice and Availability.

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Contact InformationContact Information

American Innovative Healthcare SolutionsAmerican Innovative Healthcare Solutions10 W. 35th Street, 11th Floor10 W. 35th Street, 11th Floor

Chicago, IL 60616Chicago, IL 60616

Independents such as; Independent Consultant Relationships, Opportunites Independents such as; Independent Consultant Relationships, Opportunites per State (Relationships and Time) (Convert Contacts to opportunites per State (Relationships and Time) (Convert Contacts to opportunites

in Healthcare)in Healthcare)

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Contact Information:Contact Information:

Robert J. SommerfeldRobert J. SommerfeldSommerfed@aol.com

dha1826@sbcglobal.netdha1826@sbcglobal.net23