Mental Health Medi-Cal Clinical Documentation …...Chapters in this Training Curricula San...

Mental Health Medi-Cal Clinical

Documentation Standards:

Non-Hospital (Outpatient)

Specialty Mental Health Services

San Francisco Mental Health Plan (SFMHP)

Behavioral Health Services (BHS)

BHS Quality Management

November/December 2018

Requirements & Resources

• Levels of Requirements & Authority:

San Francisco Mental Health Plan (Nov/Dec 2018) 2

Level DepartmentAgency/

BodiesExamples of Authority

Federal

US Dept. of

Health & Human

Services (HHS)

• CMS

• HHS-OIG

• State Medicaid Plan (contract between CA & CMS)

• Social Security Act (authorizing legislation)

State

CA Dept. of

Heath & Human

Services

• DHCS

• Mental Health Plan Contract (contract between

State & County)

• CCR Title 9, Chapter 11 (regulations for

implementation)

CountySF Dept. of

Public Health

• BHS

• BOCC

• Compliance

• P-600 Boilerplate Contract (contract between DPH

& Contractor)

• Policies, Procedures & Documentation Manuals

Provider (private entity)• Accrediting

Body

• Articles of Incorporation

• Charter/Bylaws


• Requirements from State Regulation & Contract:

• Mental Health Plans (MHPs) are responsible for setting standards and implementing processes that support the understanding of and compliance with documentation standards set forth by DHCS and the MHP (p23, MHP-DHCS Boilerplate Contract, 2013-2018)

• Providers/organizations are required to: (a) maintain certification and/or licensure for services; (b) maintain client records in accordance with Federal/State/Local standards & (c) meet the MHP Quality Management Program standards (CCR Title 9, §1810.435)



• State Resources:

• Contracts/Agreements Between CA State & Federal Government:

• Medicaid State Plan http://www.dhcs.ca.gov/formsandpubs/laws/Pages/CaliforniStatePlan.aspx

• CHIP State Plan http://www.dhcs.ca.gov/formsandpubs/laws/Pages/Title-XXI-SPAs.aspx

• Medi-Cal Waivers http://www.dhcs.ca.gov/services/Pages/Medi-CalWaivers.aspx

• State Plan Amendments http://www.dhcs.ca.gov/formsandpubs/laws/Pages/ApprovedSPA.aspx

• Guidance/Authority Between CA State and County MHPs:

• MHP Boilerplate Contract http://www.dhcs.ca.gov/services/MH/Pages/POCB-MentalHealth-Overview.aspx

• MHSUDS Info Notices http://www.dhcs.ca.gov/formsandpubs/Pages/MHSUDS-Information-Notices.aspx

• CA Code of Regulation https://govt.westlaw.com/calregs/Index?transitionType=Default&contextData=(sc.Default)

• CA Legislation http://leginfo.legislature.ca.gov/faces/codes.xhtml


http://www.dhcs.ca.gov/formsandpubs/laws/Pages/CaliforniStatePlan.aspx

http://www.dhcs.ca.gov/formsandpubs/laws/Pages/Title-XXI-SPAs.aspx

http://www.dhcs.ca.gov/services/Pages/Medi-CalWaivers.aspx

http://www.dhcs.ca.gov/services/Pages/Medi-CalWaivers.aspx

http://www.dhcs.ca.gov/services/MH/Pages/POCB-MentalHealth-Overview.aspx

http://www.dhcs.ca.gov/formsandpubs/Pages/MHSUDS-Information-Notices.aspx

https://govt.westlaw.com/calregs/Index?transitionType=Default&contextData=(sc.Default)

http://leginfo.legislature.ca.gov/faces/codes.xhtml


• BHS Resources:

• Clinical documentation support: BHS’ Quality Management Clinical Documentation Improvement Program (CDIP)

• BHS Policy & Procedures: refer to BHS website…


Policy Name Policy # Gist

CBHS Medical

Records Policy3.10-02

• Describes general requirements, defines medical records

• Describes each form (assessment, TPOC, diagnosis)

CBHS Medical

Record Procedures

for Closing Cases

3.10-05 • Criteria when a case must be closed

• Conditions when a closing summary is required vs. not

Behavioral Health

Progress Notes

3.10-11 • Due dates for progress notes

• Required format and elements

Note: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSmnuPolyProc.asp


• BHS Resources:

• Regulatory compliance support: DPH’s Office of Compliance and Privacy Affairs and BHS’ Compliance Office

• Contract compliance support: DPH’s Business Office of Contract Compliance (BOCC)


Chapters in this Training Curricula


Chapter and Title

1. Clinical Documentation in an Electronic Health Record (Avatar Example)

2. Logic of Mental Health Medi-Cal Insurance

3. Medical Necessity for Non-Hospital (Outpatient) Mental Health Medi-Cal

Specialty Mental Health Services (SMHS)

4. Credentialing, Qualifications and Billing Privileges

5. Assessments

6. Client Plans/Treatment Plan of Care (TPOC)

7. Outpatient Services & Progress Notes

8. Insights DHCS (2015 & 2017)

Agenda For Today


Chapter and Title Objective

1. Clinical Documentation in an Electronic

Health Record (Avatar Example)

• Primary strategy = “read the prompts on the

screen….”

2. Logic of Mental Health Medi-Cal Insurance• “Golden Thread” = Logic of Medi-Cal + Logic

of Clinical Practice

3. Medical Necessity for Non-Hospital

(Outpatient) Mental Health Medi-Cal SMHS• 4 Required Elements and 4 Pathways

4. Credentialing, Qualifications and Billing

Privileges

• Who are you in this Managed Care

Organization?

5. Assessments • What is the problem (11 elements)?

6. Client Plans/Treatment Plan of Care

(TPOC)• Why does the problem exist (11 elements)?

7. Outpatient Services & Progress Notes • How to address the problem (11 elements)?

8. Insights DHCS (2015 & 2017) • How does DHCS think?

Chapter 1:

Clinical Documentation in an Electronic Health Record

(Avatar Example)


1: Clinical Documentation in an EHR

• It’s easy to get overwhelmed and/or disoriented in a clinical documentation training!

• REMEMBER: if you read the sentence prompts that appear on the Avatar EHR screen and answer them specifically, then you are on the right track!



• Children Aged 0-4 Assessment:

• 18 Sections—respond to the prompts on the screen


• Children Aged 5-18 Assessment:




• Adult/Older Adult-Short/Long Assessment:




• TPOC (All Clients):

• 4 Levels: Respond to the prompts on the screen



Chapter 2:

Logic of Mental Health Medi-Cal Insurance


2: Logic of Mental Health Medi-Cal


Insurance Company

(they sell the insurance policy)

Managed Care Org

(they operate/implement the benefits)

Customer/Client

(they buy insurance policy)

Provider

(they contract for/provide services)



Insurance Company

(they sell the insurance policy)

Managed Care Org

(they operate/implement the benefits)

Customer/Client

(they buy insurance policy)

Provider

(they contract for/provide services)

Medi-Cal

Beneficiary

California

Dept of

Social

Services

SFDPH

Behavioral

Health

Services

Provider

(Organization,

Group, PPN)


San Francisco Mental Health Plan (Nov/Dec 2018)

“Medi-Cal Insurance”

Physical Health Medi-

Cal

Mental Health Medi-

Cal

Drug Medi-Cal

Organized Delivery

System (DMC-ODS)

San

Francisco

Health

Plan

Blue

Cross

Partner.

Plan

BHS

(County

MHP)

BHS

(County

DMC-

ODS)

• Physical health care

• Mild/Moderate MH care

• Autism Spectrum/BHT

• SMHS

• Moderate

to severe

MH care

• SUD

Treatment

Services

18



Area Clinic Model Rehabilitation Model

Definition from

Federal Social

Security Act

§1905(a)(9): “Clinic services [are

those] furnished by or under the

direction of a physician, without

regard to whether the clinic itself is

administered by a physician,

including such services furnished

outside the clinic by clinic personnel

to an eligible individual who does

not reside in a permanent dwelling

or does not have a fixed home or

mailing address”

§1905(a)(13): “Other diagnostic, screening,

preventive, and rehabilitative services,

including any medical or remedial services

(provided in a facility, a home, or other setting)

recommended by a physician or other

licensed practitioner of the healing arts

[LPHA] within the scope of their practice under

State law, for the maximum reduction of

physical or mental disability and restoration

of an individual to the best possible functional

level”

Treatment

ModelMedical model Recovery model

Focus Stabilization Active treatment and participation

Locations Clinic-based Community-based

Type of StaffLicensed; higher degree

professionals

Professionals, mental health technicians and

peer specialists

Organizational

ModelOrganized clinics

Organizations that provide one or more

covered services

Source: https://aspe.hhs.gov/system/files/pdf/74111/handbook.pdf


• Logic of Medi-Cal reflects our clinical work!


I conduct an

assessment:

“what is the problem?”

I create a treatment

plan:

“why the problem

exists”

I provide

interventions:

“how we address the

problem”

Establish Diagnosis

& Functional

Impairments

Create Treatment

Plan/Client Plan

Provide Treatment

Interventions

Clinical

Practice

M-Cal

Logic

“The Golden Thread” of Clinical Practice & Mental Health Medi-Cal

20


• Logic of Medi-Cal determines the services you can bill:


Unplanned Services

& Activities

Planned

Services

& Activities

21


• Example Algorithm: Health vs. Mental Health Plan Services (for adult client)


List A List B List C

❑Persistent symptoms & impairments after

2 recent medication trials

❑Multiple co-morbid health and mental

health conditions

❑Behavior problems (aggressive/self-

destructive/assaultive/extreme isolation)

❑Excessive ED visits or 911 calls

❑Bipolar disorder

❑Trauma/recent loss/significant life

stressors

❑Depressive symptoms

❑Anxiety symptoms

❑Homelessness/housing instability

resulting from mental health condition

❑ADHD symptoms

❑Lack of diagnostic clarity

❑2 or more psychiatric hospitalizations

within 12

❑Functionally significant, non-substance

induced paranoia, delusions,

hallucinations, mania,

❑dissociative symptoms, depression,

personality disorder

❑Suicidal/Homicidal preoccupation with

plan or behavior in past year

❑Transitional Age Youth with prodromal

psychotic symptoms

❑Eating disorder with medical

complications (with medical condition

being treated by Health Plan)

❑Substance use

disorder not

responding to

SBI (screening

& brief

intervention at

primary care)

22


• Physical Health vs. Mental Health Payer: Example Algorithm


Specialty Mental Health (County MH Plan)

>4 from list A or >1 from list B

Non-Specialty Mental Health (Health Plan/Beacon):

<3 from list A and 0 from list B

Screening forms (0-4yrs; 5-17yrs; >18yrs) posted to SF Health Plan website

23

http://www.sfhp.org/providers/provider-resources/mental-health-resources/

Chapter 3:

Medical Necessity for

Non-Hospital (Outpatient) Services


3: Medical Necessity

• Medical Necessity in Concept:

• In 2012, the Institute of Medicine (IOM) convened a group of experts to identify the common elements of medical necessity reflected across payer sources

• Prudent provider with authority: recommended by eligible provider acting with practicality, wisdom and judiciousness;

• Medical/Rehabilitative purpose: purpose is to treat a condition (medical condition; functional condition);

• Scope: type, frequency, extent, site and duration of the service/procedure should be clinically appropriate;




• Medical Necessity in Concept:

• Evidence: should be in accordance with generally accepted standards of practice (e.g., scientific evidence, expert opinion);

• Value: should be cost-effective (not “least costly,” but rather, not more expensive than other acceptable/effective treatments);

• Not Primarily for Convenience: not be primarily for (a) the convenience of the client or provider or (b) the economic benefit of the health plan/purchaser;

• Individualized: medically necessary for a particular client and thus, requires an individual assessment

• Appropriately Signed Treatment Plan: a service must have been ordered and provided though a current and appropriately signed treatment plan; 26


• Medical Necessity in Concept (cont.):

• Client’s Willingness to Participate and Client’s Ability to Benefit: client must be willing to participate in the treatment (and cognitive ability to benefit from the service);

• Active Treatment Plan and Sufficient Intensity of Treatment: must be an active treatment plan with services in sufficient intensity and duration, given generally accepted standards of practice



• Medical Necessity in Regulation: CCR, Title 9, Chapter 11




• Medical Necessity in Pictures:

29


• Medical Necessity in Practice (Four “Specials” of Medical Necessity):

1. Special diagnosis (appears on a list)

2. Special impairments (current/significant vs. significant deterioration)

3. Special interventions (reduce current/significant vs. prevent significant deterioration)

4. Special setting (not physical health problem)

Citations: (Diagnosis) CCR Title 9, §1830.205(b)(1)(A-R); (Impairments) CCR Title 9, §1830.205(b)(2)(A)-(C) and CCR Title 9, §1830.210; (Interventions) CCR Title 9, §1830.205(b)(3)(B)(1)-(3) and CCR Title 9, §1830.210



• Included Mental Health Diagnosis (“Special” Diagnosis)

• Your assessment will describe the symptoms, behaviors and differential diagnosis using DSM.

• Primary MH Dx = Mental Health Medi-Cal

• Primary SUD Dx = Drug Medi-Cal/ODS

• Primary Medical Dx = Physical Health M-Cal

• MH problems 2 to Medical = as above

• Adults with Mild/Moderate MH problems = as above

• Tip: SMHS = Special Diagnosis—one that appears on the DHCS list (not just any old dx!)



• Included Mental Health Diagnosis (“Special” Diagnosis)

• In 2015, DHCS published updated list of Covered/Included Diagnoses for SMHS (Formatted as “Crosswalk” from DSM to ICD-10)

• Annually, the codes associated with a given diagnosis can change, so you must ensure you are using the correct code



• Functional Impairments (“Special Impairments”):

• Your assessment will describe the domain and the nature of the functional impairment that stem from the mental health diagnosis.


DOMAINS of Life Functioning NATURE of Functional Impairments

• Living situation

• Daily activities and functioning

• Family relations

• Social relations

• Finances

• Legal and safety issues

• Work and school

• Health

• Cultural components

• Potential for exploitation

1. Current, significant impairment in functioning

2. Reasonable probability of significant

deterioration in functioning

3. For children, reasonable probability that child

will not progress developmentally as

individually appropriate

4. If EPSDT-eligible, a condition can be

corrected or ameliorated

33


• Treatment Interventions meet two criteria:

• The focus of the proposed/actual interventions must address the functional impairment identified as a result of the qualifying mental health diagnosis

• Focus = functional impairments

• Proposed interventions = creating Client Plan/TPOC

• Actual interventions = creating Progress Notes



• Treatment Interventions meet two criteria (cont..):

• Expectation that proposed/actual interventions must do one of the following:

• Significantly diminish the functional impairment (“today”)

• Prevent significant deterioration in functioning (“tomorrow”)

• Allow for a child to progress developmentally as individually appropriate

• Correct/ameliorate the condition for EPSDT/Full-Scope Medi-Cal, <21 years



• Tip: These are clinical stories…line up your functional impairments & interventions.


Functional Impairment Pathway Treatment Interventions Pathway

#1: Client has current significant

impairments…

…my interventions will significantly diminish

impairments

#2: Client has probability of significant

deterioration…

…my interventions will prevent significant

deterioration in functioning

#3: Child client has probability of child not

progressing developmentally…

…interventions allow the child to progress

developmentally

#4: Child client has Full-scope Medi-Cal +

<21yrs + a condition that SMHS can correct

or ameliorate…

…interventions correct or ameliorate the

condition

36


• The Condition Would Not Be Responsive to Physical Health Care-Based Treatment:

• The condition (aka functiona impairment) that exists as a result of a covered diagnosis) would not be responsive to physical health care based treatment.

• Examples:

• Depression related to a thyroid condition.

• Traumatic brain injury that leads to violent behaviors.



• DEEP DIVE: why are mental health professionals so confused about functional impairments?

• DSM is good for “disease” and bad for “disability”:

• “Impairment in functioning” is not defined in DSM, but is a required element of a diagnosis;

• DSM is good for “symptoms” and bad for “subjective experience of disease and disability”

• “Clinically significant distress” is not defined in DSM, but is a required element of a diagnosis



• DEEP DIVE: why are mental health professionals so confused about “functional impairments?


Source: DSM-5, page 20

Source: DSM-5, page 21


• DEEP DIVE: why do mental health professionals not understand functional impairments?

• Reality: at least three different constructs to explicitly consider and describe:

• #1: Mental disease/illness

• #2: Clinical significance of the disease/illness

• #3: Severity of the disease/illness



• DEEP DIVE: the cause for confusion…our DSM conflates three different constructs!


Mental

Illness/

Disease

Clinical

Significance

Severity

#1 #2 #3


• In DSM, mental diseases/illnesses are defined/operationalized through expert consensus

• Expert consensus = agreement among people if experiences/behaviors represent “normalcy” or “psychopathology” (Sartorius,

2009)

• Mental health professionals feel most comfortable focusing on a disease because we are trained in the “medical-model” and the diagnostic criteria have been operationalized via experts


Mental Illness/

Disease

#1


• Forced Choice in DSM-5: the disturbance causes clinically significant distress or impairment in social, occupational, important area of functioning

• Impairment = limitations that stem from illness; the outcome of a disease; disability; dysfunction in role functioning; decrements in functioning of the body/brain; disabling consequences of a disease

• Distress = suffering; distress; anxiety subjective distress; emotional distress; persistent distress; excessive and recurrent distress

• Remember—don’t pathologize “normal” and/or transient distress! The key phrase is clinical significance!


Clinical

Significance of

the Mental

Illness/Disease

#2



• Even Axis 5/Global Assessment of Functioning is unclear: score represents severity of both symptoms & functioning!

• Conundrum: severity of symptoms ≠ severity of ≠ impairments ≠ severity of distress

• Ways to think about “severity”:

• meets a criteria/threshold (“score of 30 = mild depression,” “score of 2 = requires action”)

• progression of disease (“early vs. advanced stage,” “prodromal symptoms vs. fully-developed illness”)

• case complications (“disabled in two domains,” “has medical and MH illnesses”)

• communimetics (“agreement from client, family and case manager that this is a real problem”)

Severity

44

#3


• DEEP DIVE: improved thinking for clinical formulations…

45

Mental

Illness/

Disease

• Meets criteria for mental illness/disease?

• Presence of symptoms/behaviors identified by experts?

Clinical

Significance

• Does the client experience distress?

• Is client disabled/limited in the environment?

Severity

• Disease severity?

• Distress severity?

• Disability severity?

#1

#2

#3



• DEEP DIVE: improved thinking for TPOCs…

• TPOC objectives should focus on functional impairment

• Symptom reduction is a focus for prescribers (in and of themselves, medications cannot restore functioning)

• For psychosocial staff, focus on symptom reduction initially (to reduce distress and build hope) and when booster training is needed (new skills, strategies)

• Distress-focused objectives are likely short-term and present early in treatment (and/or during acute periods)

• Severity can be used for measurable change (“client is very angry, 90 on SUDS, and wants to be less angry next week 70 on SUDS”)



• DEEP DIVE: CDIP examples…


Diagnosis &

Key SymptomDynamics & Mechanisms

Domain and Nature of

Impairment

ADHD with

distractibility

• can’t focus/pay attention in class (not able to

receive classroom instruction and content)

• has developed maladaptive coping skills in school

to compensate for his disability

• Domain = School

• Nature = Current

significant impairment

Schizophrenia

with auditory

hallucinations

• is confused and agitated in placement (cannot

discern real voices from hallucinations)

• is aggressive (yells and spits) at roommate and

staff (risk of losing placement)

• Domain = Living



Schizoaffective

with paranoia

• is easily overwhelmed and stressed by

internal/external environment (antagonizes his

paranoia and is unsure if he can “trust” staff)

• lack of trust leads to refusing his psych meds as

well as his diabetes meds (increasingly severe

symptoms)

• Domain = Medical




• DEEP DIVE: CDIP examples…


Diagnosis &

Key SymptomDynamics & Mechanisms

Domain and Nature of

Impairment

Schizophrenia

with

disorganized

thinking

• His behavior appears bizarre and strangers are

intimidated by his intrusive social interruptions

(symptoms are not managed)

• client is lonely, isolated and becoming more withdrawn

• Domain = Social



Delusional

disorder with

grandiosity

• believes he is wealthy and has social/financial resources

available (refuses to acknowledge his homelessness)

• client refuses to fill out paperwork to access housing and

benefits

• Domain = Living



GAD with

worry

• does not recognize or manage symptoms—finds himself

“zoning out” multiple times a day at work as he

ruminates

• work supervisor has given the client three verbal

warnings—is on probation and may lose his job

• Domain = Vocational/

Work



Chapter 4:

Credentialing, Qualifications and Billing Privileges

49San Francisco Mental Health Plan (Nov/Dec 2018)

4: Credentialing & Privileges

• SFDPH-BHS; Mental Health Staffing Qualifications for Service & Billing Privileges Matrix:


DPH

Compliance

& Privacy

Affairs

creates &

maintains

the Service

& Billing

Privileges

Matrix…

contact BHS

Compliance

office


• Scope of Practice:

• Terminology used by state licensing boards ‘for various healthcare-related fields that defines the procedures, actions, and processes that are permitted for the licensed individual. The scope of practice is limited to that which the individual has received education and clinical experience, and in which he/she has demonstrated competency’ (ps 11-12, BHS Documentation Manual, 2017)

• The California Department of Consumer Affairs (DCA) is the regulatory body that licenses professionals, educates consumers and enforces consumer laws (http://www.dca.ca.gov/about_dca/major_functions.shtml).

• There are 42 licensing Boards within DCA



• Licensed Practitioner of the Healing Arts (LPHA) :

• The Federal Medicaid rules introduced the term LPHA, but did not provide a definition—generally taken as “any health practitioner …who is licensed in the State to diagnose and treat individuals with the physical or mental disability or functional limitations at issue, and operating within the scope of practice defined in State law” (ps 12-13, BHS Documentation Manual, 2017)

• BHS LPHA (aka “Licensed Mental Health Professionals, LMPH):

1. Licensed Physician (MD/DO)

2. Licensed Nurse Practitioner (NP)

3. Licensed Clinical Nurse Specialist (CNS)

4. Licensed Clinical Social Worker (LCSW)

5. Licensed Marriage and Family Therapy (LMFT)

6. Licensed Professional Clinical Counselor (LPPC)

7. Licensed Psychologist (PhD/PsyD).



• Waivered/Registered LPHA:

• §1810.254 of CCR Title 9 defines “Waivered/Registered Professionals” as an individual who has a waiver of psychologist licensure issued by the Department or has registered with the corresponding state licensing authority for psychologists, marriage and family therapist, [professional counselor] or clinical social workers to obtain supervised clinical hours for psychologist, marriage and family therapist [professional counselor] or clinical social worker license.”

• BHS Waivered/Registered LPHA:

1. Associate Clinical Social Worker (ASW)

2. Associate Marriage and Family Therapist (AMFT)

3. Associate Professional Clinical Counselor (APCC)San Francisco Mental Health Plan (Nov/Dec 2018) 53


• Non-LPHA Nurses, Psychiatric Technicians & Pharmacists :

• The SFDPH-BHS Service and Staff Billing Privileges Matrixidentifies the following as a non-LPHA Nurses, Psychiatric Technicians and Pharmacists:

1. Registered Nurse with only Bachelor’s or Associates degree

2. Licensed Vocational Nurse

3. Psychiatric Technician

4. Pharmacist



• Mental Health Rehabilitation Specialist (MHRS):

• The Mental Health Rehabilitation Specialist (MHRS) position is defined in CCR Title 9 as:

A mental health rehabilitation specialist shall be an individual who has a baccalaureate degree and four years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. Up to two years of graduate professional education may be substituted for the experience requirement on a year-for-year basis; up to two years of post associate arts clinical experience may be substituted for the required educational experience in addition to the requirement of four years' experience in a mental health setting (CCR, Title 9, §630).



• Mental Health Rehabilitation Specialist (MHRS):

• MHRS staff are given a reasonably broad range of privileges in the SMHS program based on two factors:

• Prior Work Experience: MHRS staff must have accrued work experience, providing services to clients, in a field closely related to mental health (in addition to having, at minimum, an Associates degree)

• Medicaid’s Rehabilitation Services Option: the continuum of services available under the Rehabilitation Services Option includes more than just clinical treatments/interventions like medication and therapy.

• Remember: MHRS staff cannot work independently—require LPHA co-signatures on TPOC, are restricted from some portions of assessment, etc.



• Mental Health Workers (“Other Qualified Provider”)

• California’s Medicaid State Plan defines another category of provider in the SMHS program, an “Other Qualified Provider”:

An individual at least 18 years of age with a high school diploma or equivalent degree determined to be qualified to provide the service by the county mental health department (SPA # 12-025; “Qualification of Providers”).

• Within BHS, the “Other Qualified Provider” category has been operationalized as a “Mental Health Worker” (MHW) who receives training and works closely under the direction of an MHRS, LPHA or Waivered/Registered LPHA

• MHW has narrow band of privileges–must have a co-signature on every progress note (either an MHRS or a LPHA).



• Graduate-Level Student Enrolled in Academic Program

• Clarifications from DHCS (see p15 of BHS Documentation Manual, 2017):

• Student’s scope of practice depends on their particular program

• Non-licensed trainees, interns, and assistants must be under the immediate supervision of a LMHP who shall be responsible for ensuring that the extent, kind, and quality of the services performed are consistent with his or her training and experience and be responsible for his or her compliance with applicable state law

• If students and trainees do not meet the definition of any of the other defined providers under the State Plan, they may provide some services as Other Qualified Providers under the direction of a LMHP who is authorized to direct services



• Restricted Functions & Roles in SMHS:

• Directing Others:

• For clinical services, the role of “directing others to provide SMHS” means “acting as a clinical team leader, direct or functional supervision of service delivery, or approval of client plans. Individuals are not required to be physically present at the service site to execute direction. The licensed professional directing service assumes ultimate responsibility for the SMHS provided.

• The following categories of staff may direct others in providing SMHS:

• LPHA

• Waivered/Registered LPHA




• Under the Direction Of:

• For clinical services, the role of “providing services under the direction of” means the requirement to work under the direction of a licensed professional operating within their scope of practice

• Per DHCS, the following providers must work under the direction of a licensed professional (and the staff themselves must be licensed):

• Licensed Vocational Nurses

• Licensed Psychiatric Technicians

• Physicians Assistants

• Pharmacists

• Occupational Therapists




• Head of Service:

• For an organization’s Medi-Cal certification, the role of “Head of Service” is defined in CCR Title 9 (§1810.435) and refers to the organization’s requirement to “have as head of service a licensed mental health professional or mental health rehabilitation specialist as described in Sections 622 through 630.”

• Remember that organizationally, an MHRS staff can be the Head of Service per §1810.435, but clinically, the LPHA is required for Assessment, Treatment Plan of Care and it is the licensed professional directing service assumes ultimate responsibility for the SMHS provided.


Chapter 5: Assessments


5: Assessments

• “Assessment” in SMHS: Words Matter!

• Assessment Service: as you conduct your clinical assessment, some of your activities will meet the DHCS definition of “Assessment Service” and you can bill for that Assessment Service by writing a progress note.

• We will learn the DHCS definition of “Assessment Service”!


5: Assessments

• “Assessment” in SMHS (cont..)

• Assessment Document: you will use an electronic health record (EHR) to create a document—that document contains all of your clinical assessment information. DHCS requires that your Assessment Document include 11 items.

• We will learn the 11 required items!

• Currently, SFDPH-BHS’ EHR is Avatar (by Netsmart Technologies).

• In the future, the entire San Francisco Health Network will transition to a product created by EPIC (www.epic.com).


5: Assessments

• “Assessment” in SMHS (cont.):

• Assessment Phase of Treatment: One phase of mental health treatment is the “Assessment Phase.”

• The “due date” for an initial assessment and annual assessment varies by the type of service being provided!

• See the table from BHS Documentation Manual (“BHS Standards for Assessment Timeliness & Frequency” page 28)


5: Assessments

• “Assessment” in SMHS (cont.):


5: Assessments

“Assessment” means a service activity designed to

evaluate the current status of a beneficiary’s mental,

emotional, or behavioral health. Assessment includes

but is not limited to one or more of the following: mental

status determination, analysis of the beneficiary’s

clinical history; analysis of relevant cultural issues

and history; diagnosis; and the use of testing

procedures (CCR, Title 9, Chapter 11 §1810.204)


5: Assessments

• Did I provide an assessment service?

• Evaluate the client’s current status?

• The current mental, emotional or behavioral health?

• Activities including…

• Mental status determination?

• Analysis of clinical history?

• Analysis of relevant cultural issues/history?

• Diagnosis?

• Use of testing procedures?


5: Assessments

• The Assessment Document is important!

• The Assessment Document will show and communicate that the client has a current mental health diagnosis (Element #1-Medical

Necessity).

• The Assessment Document will show and communicate the client’s functional impairments in an important area of life functioning (Element #2-Medical Necessity).

• The Assessment Document and the client’s input will drive the creation of a Client Plan/Treatment Plan (Element #3-Medical

Necessity).


5: Assessments

• You will fill out every section of the Assessment Document. Do not leave blanks—if you don’t have the info, then say when/how you expect to get it.

• SFDPH-BHS has designed their Assessment Document to capture the 11 items that must be present on every Assessment Document (per DHCS).


5: Assessments

• The 11 Required Items for Every Assessment Document:

• #1/Presenting problem: The beneficiary’s chief complaint, history of presenting problem(s) including current level of functioning, relevant family history and current family information;

• #2/Relevant conditions & psychosocial factors: Those factors affecting the beneficiary’s physical health and mental health including, as applicable; living situation, daily activities, social support, cultural and linguistic factors, and history of trauma or exposure to trauma;

Source: MHP Boilerplate Contract (2013-2018), Exhibit A, Attachment I-Service, Administrative & Operational Requirements


Per DHCS’ IN 17-040, restricted to LPHA,

Waivered/Registered LPHA & Graduate

Students Enrolled in School

5: Assessments

• The 11 Required Items for Every Assessment Document (cont..):

• #3/Mental Health History: Previous treatment, including providers, therapeutic modality (e.g., medications, psychosocial treatments) and response, and inpatient admissions. If possible, include information from other sources of clinical data such as previous mental health records and relevant psychological testing or consultation reports;

• #4/Medical History: Relevant physical health conditions reported by the beneficiary or a significant support person. Include name and address of current source of medical treatment. For children and adolescents the history must include prenatal and perinatal events and relevant/significant developmental history. If possible, include other medical information from medical records or relevant consultation reports;


5: Assessments


• #5/Medications: Information about medications the beneficiary has received, or is receiving, to treat mental health and medical conditions, including duration of medical treatment. The assessment must include documentation of the absence or presence of allergies or adverse reactions to medications and documentation of an informed consent for medications;

• #6/Substance Exposure/Substance Use: Past and present use of tobacco, alcohol, caffeine, CAM (complementary and alternative medications) and over-the-counter drugs, and illicit drugs;



Waivered/Registered LPHA & Graduate Students Enrolled

in School

5: Assessments


• #7/Client Strengths: Documentation of the beneficiary’s strengths in achieving client plan goals related to the beneficiary’s mental health needs and functional impairments as a result of the mental health diagnosis;

• #8/Risks: Situations that present a risk to the beneficiary and/or others, including past or current trauma;

• #9/Mental status examination




in School

5: Assessments


• #10/Complete Diagnosis: A diagnosis from the current ICD-code must be documented, consistent with the presenting problems, history, mental status examination and/or other clinical data; including any current medical diagnoses.

• Additional clarifying formulation information, as needed:




in School

5: Assessments

• Remember

• You cannot provide treatment services until the assessment and treatment plan of care are completed (only, “Crisis Intervention” if there is a crisis)


Unplanned Services

& Activities

Planned

Services

& Activities

Chapter 6:

Client Plans/Treatment Plan of Care (TPOC)


6: Treatment Plan of Care (TPOC)

• Let’s take a Peek at the Avatar TPOC:

• SFDPH-BHS has designed their Client Plan/TPOC to capture the 11 items that must be present on every Client Plan/TPOC (per DHCS).

• Avatar TPOC Worksheet: IT has created a field-by-field replication of the Avatar TPOC.



• Client Plans in SMHS (CCR, Title 9, Chapter 11 §1810.205.2):

“Client Plan” means a plan for the provision of specialty mental

health services to an individual beneficiary who meets the

medical necessity criteria in Sections 1830.205 or 1830.210



• The Client Plan is important!

• The Client Plan must address the mental health needsidentified in the current assessment (The Golden Thread…assessment→impairments)

• The Client Plan must have Goals/Objectives that address the functional impairments (The Golden Thread…assessment→impairments)

• The Client Plan must be updated when there are significant changes in the client’s condition (at a minimum, updated Annually).



• Client Plan Timeliness & Frequency:

• The “due date” for an initial TPOC and annual TPOC is based on the type of service being provided!

• Table from BHS Documentation Manual (“BHS Standards for TPOC Timeliness & Frequency” page 40)



•


Client Plan Timeliness & Frequency:


• The 11 Required Items for Every Client Plan/TPOC :

• #1/Client Plan Updates: The Initial Client Plan is finalized on time (based on type of service). The client plan been updated at least annually and/or when there are significant changes in the beneficiary's condition.

• #2/Objectives: Client Plan objectives must be specific, observable, and/or specific quantifiable goals/treatment objectives related to the beneficiary’s mental health needs and functional impairments as a result of the mental health diagnosis.

Source: MHP Boilerplate Contract (2013-2018), Exhibit A, Attachment I-Service, Administrative & Operational Requirements




• #3/Interventions: The Client Plan contains the proposed type(s) of interventions/modalities. There must be a detailed description of the intervention to be provided.

• #4/Frequency of Interventions: The Client Plan includes the proposed frequency of the intervention(s).

• #5/Duration of Interventions: The Client Plan includes the proposed duration of the intervention(s).

• NOTE: “duration” includes both the Units of Service as well as calendar—for example, 50mins of therapy for 12mos




• #6/Target of Interventions: The Client Plan interventions focus on and address the identified functional impairments as a result of the mental disorder or emotional disturbance.

• #7/Consistency of Interventions with Objectives & Diagnosis: The Client Plan interventions are consistent with both: (1) Client Plan goal(s)/treatment objective(s) and (2) the qualifying diagnoses.




• #8/Staff signatures: The Client Plan is signed by:

• (1) Person providing the service(s) or

• (2) Person representing a team or program providing the service(s) or,

• (3) A person representing the MHP providing the service(s) or

• (4) Co-signed by a LPHA (if the Client Plan is used to establish that services are provided under the direction of a LPHA, and if the signing staff is not a LPHA)




• #9/Client Participation & Agreement with Plan:

• The client's participation in and agreement with the Client Plan is documented by one of the following: (1) reference to the client's participation in/agreement written within the body of the Client Plan, (2) the client's signature* on the client plan or (3) a description of the client's participation in/agreement documented in the medical record.

• The client's signature* (or client's legal representative's signature) must appear on the Client Plan if both of the following are true: (1) the client is expected to be in long-term treatment [defined by County MHP] and (2) the Client Plan includes more than 1 type of SMHS [e.g., “Therapy” and “Collateral”].

• *If the client refuses or is unavailable to sign the Client Plan, then the Client Plan must include a written explanation of the refusal/unavailability of the signature (see updated standard)



• Planned vs. Unplanned services


Unplanned Services/Activities Planned Services/Activities• Assessment

• Plan Development

• Crisis Intervention

• Crisis Stabilization

• Specified activities within Targeted Case

Management (TCM)/Intensive Care Coordination

(ICC):

o Assessment, Plan Development and

Referral/Linkage to obtain needed services

• Specified activities within Medication Support

Services:

o Assessment, Evaluation and Plan

Development

• Urgent Medication Support Services (if

current/urgent clinical need to obtain medication is

documented)

• Collateral

• Rehabilitation

• Therapy

• Therapeutic Behavioral Services (TBS)

• Intensive Home Based Services (IHBS)

• Treatment Foster Care (TFC)

• Specified activities within TCM/ICC:

o Monitoring and Follow-up Activities

• Specified activities within Medication Support Services:

o Direct Treatment and Monitoring

• Adult Residential Services??

• Crisis Residential Services

• Day Treatment Rehabilitation and Intensive



• #10/Evidence of Offering Client Copy of Plan: The Client Plan will include documentation that the contractor offered a copy of the client plan to the beneficiary.

• #11/Dates & Staff Degree/Title: The Client Plan must include all of the following (1) the date of service; (2) the staff's signature, professional degree and title of job/licensure; and (3) the date the documentation was entered into the medical record.



• Additional Details for the Client Plan

• DHCS clarified in IN 17-040 the standard for obtaining a client signature on a TPOC (one attempt to obtain signature that signifies the client participated in and agrees with the treatment plan). You must document the client’s refusal or unavailability in a progress note (though ongoing attempts are best practice)

• The Client Plan is officially “finalized” after all required LPHA staffsignatures are in place and dated.

• You must finalize the Client Plan before providing treatment services. In other words, you cannot bill “planned services” until the Client Plan is finalized!


Chapter 7:

Outpatient Services & Progress Notes


7: Services & Progress Notes

• Outpatient SMHS for SFDPH-BHS:

• SFDPH-BHS certifies and authorizes clinics and staff to provide a limited “package” of SMHS (“Medi-Cal certification”).

• Based on your contract, you must document the services (in minutes, days, blocks of time, etc.) in a progress note using BHS’ EHR

• Outpatient SMHS for DHCS:

• Eleven required elements for every progress note!



• The 11 Required Elements:

• #1/Relevant Aspects of Client Care: Progress notes include documentation of relevant aspects of client care, including documentation of medical necessity;

• #2/Details of the Encounter: Progress notes include documentation of beneficiary encounters, including relevant clinical decisions, when decisions are made, alternative approaches for future interventions;




• #3/Interventions & Details: Progress notes include descriptions of interventions applied, client’s response to the interventions, [how interventions reduced impairment/restored functioning/prevented deterioration in an important area of life functioning out lined in the Client Plan], and the location of the interventions;

• #4/Date of Service: Progress notes include the date the services were provided;




• #5/Referrals: Progress notes include documentation of referrals to community resources and other agencies, when appropriate;

• #6/Follow-Up Care and/or Discharge Summary: Progress notes include documentation of follow-up care or, as appropriate, a discharge summary;

• Discharge summary in and of itself is not billable!

• Could be billable: Conducting a therapeutic session with a client to create a discharge plan (and/or a therapeutic session to review a discharge plan with client).

• Never billable: (a) typing the discharge summary to print/file; (b) creating a discharge summary after your last session with client.




• #7/Service Time: Progress notes include documentation of the amount of time taken to provide services;

• #8/Signature, Degree & Licensure/Job Title: Progress notes include the signature of the person providing the service (or electronic equivalent); the person’s type of professional degree, and licensure or job title;

• #9/Date of Documentation: The date the documentation was entered in the medical record;




• #10/Timeliness, Frequency & Legibility:

• Best practice for all service types: document the service on the same day it is delivered!

• Specific timeliness standard varies by type of service (see next page for screenshots from Documentation Manual)

• If timeliness standard cannot be met, staff must include the text "Late Entry" at the beginning of the note

• Trends and patterns of late notes could be problematic on an audit!




• #11/Multi-Provider Notes: When services are being provided to, or on behalf of, a beneficiary by two or more persons at one point in time, do the progress notes include:

• Documentation of each person’s involvement in the context of the mental health needs of the beneficiary?

• The exact number of minutes used by persons providing the service?

• Signature(s) of person(s) providing the services?



• Frequency & Timeliness:



• Additional Details on Element #11: Multi-Provider Notes:

• Principles to consider when two or more providers are rendering services:

• Document why multiple staff are needed for the activity;

• Document the unique contribution for each person’s involvement;

• Prorate/apportion the staff service time across all clients in the room (regardless if Medi-Cal or other insurance)



• Additional Details on Element #11: Multi-Provider Notes:


2 Staff x

60mins =

120mins

8 clients

total

Formula for Prorating Multi-Provider Services

(#Staff) x (# Minutes) ÷ (# of clients)

(2 Staff) x (60mins) ÷ (8 Clients)

120 Staff Minutes ÷ 8 clients

15 Staff Minutes Per Client

• Prorating Example: Social Skills Group (60mins) with 2 Staff and 8 Clients…how many mins/client?

NOTE:

The best practice (and the

future of health care billing) is

to write your own note and

claim your own service/

contribution to the group


• Billing by the Minutes: “Outpatient Bundle”

• For most outpatient providers, you deliver a group of services informally referred to as the “outpatient bundle”

• If certified, providers can deliver additional child-specific services (TBS, ICC, IHBS, TFC)



• Billing by Blocks of Time

• Some services bill in blocks of time

• Day Treatment (Rehabilitation/Intensive)


• Billing by Days

• Residential-based services bill by the day

• Adult Residential

• Crisis Residential


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)

Outpatient

Bundle Services

Mental Health

ServicesTCM Med Support Crisis Interv’n

▪ Assessment

▪ Plan

Development

▪ Therapy

▪ Rehabilitation

▪ Collateral



Billing by

the

Minutes!


• Mental Health Services: DHCS Definition

• “Mental Health Services” means individual or group

therapies and interventions that are designed to provide

reduction of mental disability and restoration, improvement

or maintenance of functioning consistent with the goals of

learning, development, independent living and enhanced self-

sufficiency…[s]ervice activities may include but are not limited to

assessment, plan development, therapy, rehabilitation and

collateral.San Francisco Mental Health Plan (Nov/Dec 2018) 105


• Assessment: DHCS Definition

• “Assessment” means a service activity designed to evaluate

the current status of a beneficiary’s mental, emotional, or

behavioral health. Assessment includes but is not limited to one

or more of the following: mental status determination, analysis

of the beneficiary’s clinical history; analysis of relevant

cultural issues and history; diagnosis; and the use of testing

procedures



• Assessment: Example Text

• “Initial meeting with client for the purposes of conducting an assessment to determine medical necessity for Specialty Mental Health Services.”

• “Conducted mental status exam: client shows impaired Thought Processes (loose associations; flight of ideas) and Content (paranoid delusions) which are consistent with the reason for referral.”

• “Will continue assessment process in next meeting.”



• Plan Development: DHCS Definition

• “Plan Development” means a service activity that consists of

development of client plans, approval of client plans, and/or

monitoring of a beneficiary’s progress.



• Plan Development: Example Text

• “Met with client for the purposes of developing Client Plan objectives to address functional impairments (social problems) that result from client’s mental health diagnosis(Schizophrenia, F20.9; inability to concentrate).”

• “The client identified the following goals: ‘make food at home so I can save money’ and ‘meet more people so I can find someone to date.’”



• Therapy: DHCS Definition

• “Therapy” means a service activity that is a therapeutic

intervention that focuses primarily on symptom reduction as

a means to improve functional impairments. Therapy may be

delivered to an individual or group of beneficiaries and may

include family therapy at which the beneficiary is present.



• Therapy: DHCS Definition

• “Conducted individual therapy session to address Client Plan Objective (‘meet more people so I can find someone to date’).”

• “Implemented behavioral rehearsal intervention with client. Client was able to introduce himself and ask an appropriate open-ended questions with minimal prompts from therapist.”

• “Mental status exam: no change in thought content/ processes from initial meeting. No suicidality observed.”



• Rehabilitation: DHCS Definition

• “Rehabilitation” means a service activity which includes, but is

not limited to assistance in improving, maintaining, or

restoring a beneficiary’s or group of beneficiaries’ functional

skills, daily living skills, social and leisure skills, grooming

and personal hygiene skills, meal preparation skills, and

support resources; and/or medication education.



• Rehabilitation: Example Text

• “Conducted individual rehab session to address Client Plan Objective (‘make food at home so I can save money’).”

• “Assisted client to create a weekly calendar of food shopping activities. Initially, client was resistant to the activity. We reviewed his goals and he confirmed this is his current goal. Client agreed that he ‘gets confused sometimes’ and then created a weekly calendar and we taped the calendar to the refrigerator.”



• Collateral: DHCS Definition

•“Collateral” means a service activity to a significant

support person in a beneficiary’s life for the purpose

of meeting the needs of the beneficiary in terms of

achieving the goals of the beneficiary’s client plan. Collateral may

include but is not limited to consultation and training of the significant

support person(s) to assist in better utilization of specialty mental

health services by the beneficiary, consultation and training of the

significant support person(s) to assist in better understanding of mental

illness, and family counseling with the significant support person(s).

The beneficiary may or may not be present for this service activity.



• Collateral: Example Text

• “Conducted collateral session on phone with client’s mother, (a significant support person to the client) to address Client Plan Objective (‘make food at home so I can save money’).”

• “Consulted with mother regarding client’s weekly calendar of food shopping. Explained why the calendar is an important tool for the client. Mother agreed that when she calls the client each morning, she will cue him to look at the calendar.”



• DEEP DIVE: why are mental health professionals

so confused about Collateral?

• Reason #1: JARGON!


Varied Definitions!

• Property

• Relative

• Informational Materials

• Subordinate

• Indirect

• Ancillary

• Ancestral Stock





• Reason #1: JARGON (cont.)

• Getting Concrete: “significant support persons” in regulation

117

Significant support means PERSONS, in the opinion of the

client or the person providing services, who have or could have a

SIGNIFICANT ROLE in the successful outcome of

treatment, including but not limited to the PARENTS or legal

guardian of a client who is a minor, the LEGAL

REPRESENTATIVE of a client who is not a minor, a person

LIVING IN THE SAME HOUSEHOLD as the client, the

client’s SPOUSE, and RELATIVES of the client (Source: 9 CCR

§1810.246.1).

Narrow Definitions!

• Person

• Significant role

• Parents

• Legal Representative

• Same Household

• Spouse

• Relatives





• Reason #2: Logic & Reason

• We can logically conclude:

• “Collateral” is never going to be a staff member of behavioral health, social services, jail/probation, vocational services, etc.

• The target of the collateral will be implementing actions and activities (described in the TPOC) that help the client

• Collateral does not mean “talking”

118





• Reason #2: Logic & Reason (cont.)

• School teachers could reasonably be considered collateral if/when:

• The teacher has sufficient/meaningful access to the client (e.g., homeroom teacher sees child throughout day)

• The functional impairments include school setting, behavior, etc.

• The teacher is willing/able to consistently participate in treatment (e.g., implement behavioral interventions)

• The assessment and TPOC explicitly identify/describe the teacher a significant support person

119


• Targeted Case Management: DHCS Definition

• “Targeted Case Management” means services that assist a

beneficiary to access needed medical, educational, social,

prevocational, vocational, rehabilitative, or other community

services. The service activities may include, but are not limited

to, communication, coordination, and referral; monitoring

service delivery to ensure beneficiary access to service and

the service delivery system; monitoring of the beneficiary’s

progress; placement services; and plan development”



• Targeted Case Management: Example Text

• “Conducted TCM service on phone with vocational services staff to address Client Plan Objective (‘meet more people so I can find someone to date’).”

• “Communicated with vocational program intake staff regarding referral to the program. I was informed that client cannot begin program for 2 weeks due to staffing shortage. The intake staff member confirmed that she will call the client to introduce herself and explain the delay. I will confirm client’s understanding of the delay in next session.”




so confused about Targeted Case Management?

• Reason #1: JARGON

Case management is a generic term with multiple definitions

depending on the profession, client group, context and organizational

structure…despite the large number of definitions, common core

tasks, or steps, prevail in all practice settings: client

identification, assessment, care planning, implementation,

monitoring and reassessment*


*Smith, JE (1998). Case management: A literature review. Canadian Journal of Nursing Administration, 11(2), 93-108.





• Reason #1: JARGON (continued)

• ADMINISTRATIVE CASE MANAGEMENT: a Utilization Management activity designed to broker needed services for high-risk clients at the lowest possible price*

• Example: DPH’s Transition Unit (Kelly Hiramoto, LCSW) provides administrative case management for clients exiting Inpatient Psych (brokering a placement at a board and care)

• CLINICAL CASE MANAGEMENT: primarily focuses on optimizing clinical management and often focuses on a specific high-risk clinical condition such as diabetes or heart failure*

123

*Wickizer, TM & Lessler, D. (2002). Utilization Management: Issues, effects & future prospects. Annual Review of Public Health, 23, 233-254




• Reason #2: FEDERAL LAWS & MEDICAID RULES

• Attempts by US Government to reduce costs associated with Medicaid’s Targeted Case Management: Deficit Reduction Act of 2005

• In Medicaid, “case management” means helping beneficiaries to obtain needed services (medical and related services). This is also referred to as “non-targeted case management.”

• In Medicaid, “targeted case management” refers to case management that is restricted to specific beneficiary groups that are defined by a disease (e.g., HIV/AIDS, tuberculosis) or condition (e.g., chronic mental illness, developmental delays).

124

Sources: https://www.gpo.gov/fdsys/pkg/FR-2007-12-04/pdf/07-5903.pdf and http://www.ncsl.org/print/health/CRSTCM.pdf


https://www.gpo.gov/fdsys/pkg/FR-2007-12-04/pdf/07-5903.pdf

http://www.ncsl.org/print/health/CRSTCM.pdf



so confused about Targeted Case Management??

• Reason #3: CA’s STATE MEDICAID CONTRACT

• Seven Targeted Populations for Medi-Cal TCM:

1. Individuals Diagnosed with a Developmental Disability and Medi-Cal Beneficiaries that Meet Medical Necessity Criteria for TCM Covered as Part of the Specialty Mental Health Services Program

2. Children Under the Age of 21

3. Medically Fragile Individuals


The enumerated list of “supplements” to

our boilerplate list of services:

https://www.dhcs.ca.gov/formsandpubs/law

s/Pages/Supplements%203.1A.aspx

Of the seven

groups who are

“targeted” to

receive TCM, the

MHP is responsible

for two!




• Reason #3: CA’s STATE MEDICAID CONTRACT (cont.)

• Seven Targeted Populations for Medi-Cal TCM (cont.):

4. Children with a Individualized Education Plan (IEP) and Individualized Family Service Plan (IFSP)

5. Individuals at Risk of Institutionalization

6. Individuals in Jeopardy of Negative Health or Psycho-Social Outcomes

7. Individuals with Communicable Diseases






The enumerated

list of

“supplements” to

our boilerplate list

of services:

https://www.dhcs.ca.gov/formsandpub

s/laws/Pages/Supplements%203.1A.a

spx

https://www.dhcs.ca.gov/formsandpubs/laws/Pages/Supplements 3.1A.aspx




• Reason #4: Non-Useful Definitions vs. Useful

• TCM Definition from CCR Title 9, Chapter 11:

“Targeted Case Management” means services that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities may include, but are not limited to, communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary’s progress; placement services; and plan development.






• Reason #4: Non-Useful Definitions vs. Useful (cont.)

• TCM Definition from State Plan:

Targeted Case Management (TCM) means services that assist a beneficiary to access needed medical, alcohol and drug treatment,educational,

social, prevocational, vocational, rehabilitative, or other community services. The service activities include (dependent upon the practitioner’s

judgment regarding the activities needed to assess and/or treat the beneficiary): communication, coordination, and referral; monitoring service

delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and

plan development:

TCM may be provided face-to-face, by telephone, or by telemedicine with the beneficiary or significant support person and may be provided

anywhere in the community. TCM contacts with significant support persons may include helping the eligible beneficiary access services, identifying

needs and supports to assist the eligible beneficiary in obtaining services, providing case managers with useful feedback, and alerting case

managers to changes in the eligible beneficiary's needs (42 CFR 440.169(e)).

Targeted Case Management (TCM) means services that assist a beneficiary to access needed medical, alcohol and drug treatment,educational,

social, prevocational, vocational, rehabilitative, or other community services. The service activities include (dependent upon the practitioner’s

judgment regarding the activities needed to assess and/or treat the beneficiary): communication, coordination, and referral; monitoring service

delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and

plan development:

TCM may be provided face-to-face, by telephone, or by telemedicine with the beneficiary or significant support person and may be provided

anywhere in the community. TCM contacts with significant support persons may include helping the eligible beneficiary access services, identifying

needs and supports to assist the eligible beneficiary in obtaining services, providing case managers with useful feedback, and alerting case

managers to changes in the eligible beneficiary's needs (42 CFR 440.169(e)). 129






• TCM Definition from State Plan (cont.):

TCM includes the following assistance:

1. Comprehensive assessment and periodic reassessment of individual needs to determine the need for establishment or continuation of TCM

services to access any medical, educational, social, or other services. These assessment activities include:

a. Taking client history;

b. Identifying the individual's needs and completing related documentation, reviewing all available medical, psychosocial, and other records,

and gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary) to

form a complete assessment of the individual; and

c. Assessing support network availability, adequacy of living arrangements, financial status, employment status, and potential and training

needs. Assessments are conducted on an annual basis or at a shorter interval as appropriate.

2. Development and Periodic Revision of a Client Plan that is:

a. Based on the information collected through the assessment;

b. Specifies the goals, treatment, service activities, and assistance to address the negotiated objectives of the plan and the medical, social,

educational, and other services needed by the individual;

c. Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual's

authorized health care decision maker) and others to develop those goals;

d. Identifies a course of action to respond to the assessed needs of the eligible individual; and

e. Develops a transition plan when a beneficiary has achieved the goals of the Client Plan.

130






• TCM Definition from State Plan (cont.): 3. Referral and Related Activities:

a. To help an eligible individual obtain needed services including activities that help link an individual with medical, alcohol and drug

treatment, social, educational providers or other programs and services that are capable of providing needed services, such as making

referrals to providers for needed services and scheduling appointments for the individual;

b. To intervene with the client/others at the onset of a crisis to provide assistance in problem resolution and to coordinate or arrange for the

provision of other needed services;

c. To identify, assess, and mobilize resources to meet the client's needs. Services would typically include consultation and intervention on

behalf of the client with Social Security, schools, social services and health departments, and other community agencies, as appropriate;

and

d. Placement coordination services when necessary to address the identified mental health condition, including assessing the adequacy and

appropriateness of the client's living arrangements when needed. Services would typically include locating and coordinating the resources

necessary to facilitate a successful and appropriate placement in the least restrictive setting and consulting, as required, with the care

provider.

4. Monitoring and Follow-Up Activities:

a. Activities and contacts that are necessary to ensure the Client Plan is implemented and adequately addresses the individual's needs, and

which may be with the individual, family members, providers, or other entities or individuals and conducted as frequently as necessary, and

including at least one annual monitoring, to determine whether the following conditions are met: (1) Services are being furnished in

accordance with the individual's Client Plan; (2) Services in the Client Plan are adequate; and (3) There are changes in the needs or status

of the individual, and if so, making necessary adjustments in the Client Plan and service arrangements with providers.

b. Activities to monitor, support, and assist the client on a regular basis in developing or maintaining the skills needed to implement and

achieve the goals of the Client Plan. Services would typically include support in the use of psychiatric, medical, educational, socialization,

rehabilitation, and other social services. Monitoring and update of the Client Plan is conducted on an annual basis or at a shorter interval as

appropriate.131


• Medication Support Services: DHCS Definition

• “Medication Support” means those services that include prescribing,

administering, dispensing and monitoring of psychiatric

medications or biologicals that are necessary to alleviate the

symptoms of mental illness. Service activities may include but are

not limited to evaluation of the need for medication; evaluation of

clinical effectiveness and side effects; the obtaining of informed

consent; instruction in the use, risks and benefits of and

alternatives for medication; and collateral and plan development

related to the delivery of the service and/or assessment of the

beneficiary.



• Medication Support Services: Example Text

• “Provided Medication Support service to client to address

Client Plan Objective (‘meet more people so I can find

someone to date’).”

• “Medication management meeting to monitor client’s clinical

response to Risperidone. He reports that he takes meds as

directed (‘my mom helps to remind me’). Minimal side effects

reported. Client states he believes he is more ‘stable when I

take my meds.’ Client also reports he feels more comfortable

talking to people now “than I did last year.”



• DEEP DIVE: why are mental health professionals so confused about Medication Support Services (MSS)?

• Reason #1: Non-Useful Definitions vs. Useful

• MSS Definition from CCR Title 9, Chapter 11:

“Medication Support Services” means those services that include prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals that are necessary to alleviate the symptoms of mental illness. Service activities may include but are not limited to evaluation of the need for medication; evaluation of clinical effectiveness and side effects; the obtaining of informed consent; instruction in the use, risks and benefits of and alternatives for medication; and collateral and plan development related to the delivery of the service and/or assessment of the beneficiary.




• DEEP DIVE: why are mental health professionals so confused about Medication Support Services?


• MSS Definition from State Plan:

Medication Support Services include one or more of the following: prescribing, administering, dispensing and monitoring drug interactions

and contraindications of psychiatric medications or biologicals that are necessary to alleviate the suffering and symptoms of mental

illness. This service may also include assessing the appropriateness of reducing medication usage when clinically indicated. Medication

Support Services are individually tailored to address the beneficiary's need and are provided by a consistent provider who has an established

relationship with the beneficiary.

Services may include: providing detailed information about how medications work; different types of medications available and why they

are used; anticipated outcomes of taking a medication; the importance of continuing to take a medication even if the symptomsimprove

or disappear (as determined clinically appropriate); how the use of the medication may improve the effectiveness of other services a

beneficiary is receiving (e.g., group or individual therapy); possible side effects of medications and how to manage them; information

about medication interactions or possible complications related to using medications with alcohol or other medications or substances;

and the impact of choosing to not take medications. Medication Support Services supports beneficiaries in taking an active role in

making choices about their mental health care and helps them make specific, deliberate, and informed decisions about their treatment

options and mental health care.

Medication support services may be provided face-to-face, by telephone or by telemedicine with the beneficiary or significant support person(s) and

may be provided anywhere in the community.

This service includes one or more of the following service components: evaluation of the need for medication; evaluation of clinical

effectiveness and side effects; the obtaining of informed consent; medication education including instruction in the use, risks and

benefits of and alternatives for medication; collateral; plan development

135



• Reason #2: “Bundled Service” with Multiple “Activities”

• The expanded definition from State Plan helps us understand—MSS is a bundled service with multiple activities:


ASSESSMENT &

EVALUATION

PLAN DEVELOPMENT

TREATMENT & MONTIORING

Unplanned

Activities

within the

bundled

Medication

Support

ServicePlanned

Activities

within the

bundled

Medication

Support

Service



• Reason #3: Scenario-Specific Issues—URGENT MEDICATION

• DHCS clarified that urgent scenarios can warrant unplanned medication support services (IN17-040)!

• BHS provided guidance and direction here:1. Urgent clinical need: The client must have a current and urgent clinical need

to obtain medication that is clearly documented.

2. Recent receipt of behavioral health services: The client must have recently received behavioral health/psychiatric medication (e.g., recent discharge from inpatient hospital; recent prescribing from a primary provider). The prescriber will verify that the treatment is clinically appropriate.

3. Service sufficiency: the client’s urgent mental health need is met through the contact with the prescriber.




• Reason #4: Treating Functional Impairments, NOT DIAGNOSES!

• System confusion about “dual diagnoses” and “integrated care”

• Idiosyncratic jargon (“dual” referring to SUD? Medical? Social?)

• Low “health insurance literacy”(do not understand insurance benefits, managed care processes, etc.) source = Kaiser Family Foundation,

https://www.kff.org/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/


https://www.kff.org/health-reform/poll-finding/assessing-americans-familiarity-with-health-insurance-terms-and-concepts/


• DEEP DIVE: why are mental health professionals so

confused about Medication Support Services (MSS)?

• Reason #4: Treating Functional Impairments, NOT DIAGNOSES (cont.)!

• BHS’ updated policy (BHS Services for Integrative Assessment and Treatment):

“Medication Support Services may include prescribing, administering,

and assessment of safety, education and monitoring of psychiatric

medications or biologicals that are necessary to alleviate the symptoms

of mental illness. For the purpose of BHS mental health plan,

“psychiatric” medications are defined as any medication that is

necessary to alleviate the symptoms of mental illness including

addiction treatment medications”San Francisco Mental Health Plan (Nov/Dec 2018) 139



• Reason #4: Treating Functional Impairments, NOT DIAGNOSES (cont.)!

• New performance improvement project (PIP) for BHS:

• PROBLEM: prescribers incorrectly believe that they cannot identify an SUD diagnosis in a SMHS assessment—we cannot estimate the number of clients with a co-morbid SUD problem

• INTERVENTION: educate prescribers about “included diagnosis” and treating “functional impairments; clarify policy to allow SUD medications that address client’s mental health impairments



• Crisis Intervention: DHCS Definition

• “Crisis Intervention” means a service, lasting less than 24

hours, to or on behalf of a beneficiary for a condition that

requires more timely response than a regularly scheduled

visit. Service activities include but are not limited to one or more

of the following: assessment, collateral and therapy. Crisis

intervention is distinguished from crisis stabilization by being

delivered by providers who do not meet the crisis stabilization

contact, site, and staffing requirements described in Sections

1840.338 and 1840.348.



• Additional Services Billed in Minutes

• “Outpatient bundle” services are most familiar to outpatient providers;

• For children under age 21, additional outpatient services that are reimbursed in minutes:

• Therapeutic Behavioral Support (TBS)

• Intensive Care Coordination (ICC)


• Treatment Foster Care (TFC)




• Therapeutic Behavioral

Support (TBS)




• Therapeutic Behavioral Services

• “…a one-to-one behavioral mental health service available to children and youth with serious emotional challenges who are under 21 years old and who are eligible for a full array of Medi-Cal benefits without restrictions or limitations (full scope Medi-Cal). TBS can help children/youth and parents/caregivers, foster parents, group home staff, and school staff learn new ways of reducing and managing challenging behaviors, as well as strategies and skills to increase the kinds of behavior that will allow children and youth to be successful in their current environment. TBS is designed to help children and youth and parents and caregivers (when available) manage these behaviors utilizing short-term, measurable goals based on the needs of the child and youth and their family (page 115, BHS Documentation Manual)




• TBS is not a stand-alone service (EPSDT Supplemental SMHS)

• Clients that meet medical necessity criteria and defined class criteria:

• in a group home facility (RCL 12+)/locked treatment facility for (treatment of MH needs or child being considered by DPH for a placement in a facility described above;

• undergone at least one emergency psychiatric hospitalization related to current presenting mental health diagnosis within the preceding 24 months;

• previously received TBS while a member of the certified class or child or youth is at risk of psychiatric hospitalization.




• Intensive Care

Coordination (ICC)

• Intensive Home Based

Services (IHBS)




• Intensive Care Coordination (ICC)

• “…an intensive form of Targeted Case Management (TCM) that facilitates assessment of, care planning for, and coordination of services for children and youth. ICC includes urgent services for beneficiaries with intensive needs”

• REQUIRES A CHILD-FAMILY-TEAM (CFT)

• Intended for children who:

• Are involved in multiple child-serving systems;

• Have more intensive needs; and/or

• Whose treatment requires cross-agency collaboration


Source: DHCS (January 2018). Medi-Cal Manual for ICC, IHBS, & TFC



• Change in Policy from DHCS (IN# 16-004)

• ICC and IHBS are provided through the EPSDT benefit to all children and youth who:

• Are under the age of 21;

• Are eligible for the full scope of Medi-Cal services; and

• Meet medical necessity criteria for SMHS

• ICC and IHBS must be provided to all children and youth who meet medical necessity criteria for those services. Membership in the Katie A. subclass is not a prerequisite to receiving ICC and IHBS.





• Intensive Care Coordination (ICC)-Service Components

• Planning & Assessment of Strengths & Needs

• Ressessment of Strengths & Needs

• Referral, Monitoring & Follow-Up Activities

• Transition





• Intensive Care Coordination (ICC)-Lockouts

• Effective July 1, 2017, ICC may be provided to Medi-Cal beneficiaries, under the age of 21, who are placed in group homes or Short-Term Residential Therapeutic Program (STRTPs), if medically necessary. There is no limitation on the number of days that ICC may be provided or reimbursed

• When ICC is provided in a hospital, psychiatric health facility, community treatment facility, or psychiatric nursing facility, it will be used solely for the purpose of coordinating placement of the child or youth on discharge from those facilities (for the purpose of discharge planning, during the 30 calendar days immediately prior to the day of discharge, )






• “…individualized, strength-based interventions designed to ameliorate mental health conditions that interfere with a child’s or youth’s functioning… interventions are aimed at: helping the child/youth build skills for successful functioning in the home and community, as well as improving the family’s ability to help the child/youth successfully function in the home and in the community”

• “IHBS activities support the engagement and participation of the child/youth and his/her significant support persons. In addition, IHBS activities help the child/youth develop skills and achieve the goals and objectives of the plan





• Intensive Home-Based Services (IHBS)-Service Components

• Skills-based interventions

• Remediation/improvement of behaviors/symptoms

• Development of functional skills to improve self-care/self-regulation and participation of child in CFT/service plans

• Improvement of self-management of symptoms (including self-administration of meds)

• Education of child/family/caregivers about mental health disorder

• Support development/maintenance of social networks

• Support to address behaviors interfering with permanency, job seeking, educational, or transitioning to independent living




• DEEP DIVE: Child & Family Team (CFT) & Integrated Core Practice Model

• CFT Details from DHCS’ ICC, IHBS, TFC Medi-Cal Manual

• Composition of the CFT

• Confidentiality

• Initial/Ongoing CFT Meetings

• When to Convene a CFT Meeting

• CFT Meeting, Frequency, Location & Logistics

• CFT Meeting Preparation

• CFT Meeting Facilitation






• CFT Details from DHCS’ ICC, IHBS, TFC Medi-Cal Manual

• Claiming & Reimbursement

• provider in a CFT meeting may claim for the time he or she contributed to the CFT meeting, up to the length of the meeting, plus documentation and travel time, in accordance with Title 9, CCR, Chapter 11, Section 1840.316 (b) (3).

• Time claimed, which may include active listening time, must be supported by documentation showing what information was shared, and how it can/will be used in providing, planning, or coordinating services to the client (i.e. how the information discussed will impact the client plan).

154Source: DHCS (January 2018). Medi-Cal Manual for ICC, IHBS, & TFC



• Integrated Core Practice Model (ICPM)

• A set of practices and principles that provide practical guidance and direction to the delivery of timely, effective, and collaborative services to children/youth and their families. The ICPM sets specific expectations for practice behaviors for staff involved in direct services to children/youth and their families, as well as for supervisory and leadership

• To effectively provide medically necessary ICC, IHBS, and TFC, MHPs, child welfare and juvenile probation departments, and providers should utilize the principles of the ICPM. Specifically, there must be a CFT established to guide the services provided to children/youth and their families





• Services Billed in Blocks of Time (Hours)

• The following services are documented, billed and claimed in hours of time:

• Day Treatment Rehabilitation

• Day Treatment Intensive


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)



• Day Treatment-Rehabilitation & Intensive


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)

Day Treatment-Rehab Day Treatment-Intensive

“Day Rehabilitation” means a structured

program of rehabilitation and therapy to

improve, maintain or restore personal

independence and functioning, consistent

with requirements for learning and

development, which provides services to

a distinct group of individuals. Services

are available at least three hours and less

than 24 hours each day the program is

open. Service activities may include, but

are not limited to, assessment, plan

development, therapy, rehabilitation and

collateral.

“Day Treatment Intensive“ means a

structured, multi-disciplinary program of

therapy which may be an alternative to

hospitalization, avoid placement in a more

restrictive setting, or maintain the individual in

a community setting, which provides services

to a distinct group of individuals. Services are

available at least three hours and less than

24 hours each day the program is open.

Service activities may include, but are not

limited to, assessment, plan development,

therapy, rehabilitation and collateral.


• Day Treatment REHABILITATION

• Documentation (MHP Boilerplate 2017-2022):

• Day Treatment Rehab documentation must include:

• the date(s) of service,

• signature of the person providing the service (or electronic equivalent),

• the person’s type of professional degree, licensure or job title,

• date of signature and

• the total number of minutes/hours the beneficiary actually attended the program.

• Weekly Summary

• Monthly Collateral Contact/Note


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)


• Day Treatment INTENSIVE

• Documentation (MHP Boilerplate 2017-2022):

• Day Treatment Intensive documentation must include:

• the date(s) of service,

• signature of the person providing the service (or electronic equivalent),

• the person’s type of professional degree, licensure or job title,

• date of signature and

• the total number of minutes/hours the beneficiary actually attended the program.

• Daily Progress Notes on activities

• Weekly Clinical Summary (reviewed/signed by LPHA)

• Monthly Collateral Contact/Note


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)



• Day Treatment-Rehabilitation & Intensive

• Example tracking log


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)




• (9 CCR § 1810.210) Crisis Stabilization means a service lasting less than 24 hours, to or on behalf of a beneficiary for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy. Crisis stabilization is distinguished from crisis intervention by being delivered by providers who do meet the crisis stabilization contact, site, and staffing requirements described in 9 CCR §1840.338 and 9 CCR §1840.348.


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)



• Crisis Stabilization-Emergency Room

• Service lasting less than 24 hours provided to (or on behalf of) a beneficiary for a condition that requires a more timely response than a regularly scheduled visit. Service activities include (but are not limited to) Assessment, Collateral, and Therapy. Crisis Stabilization differs from Crisis Intervention in that stabilization is delivered by providers who meet contact, site, and staffing requirements for Crisis Stabilization described in 9 CCR §1840.338 and 9 CCR §1840.348.

• Crisis Stabilization must be provided onsite at a licensed 24-hour health care facility, as part of a hospital-based outpatient program, certified by the state to perform crisis stabilization.

• The maximum allowance provided in CCR, Title 22 for ‘Crisis Stabilization-Emergency Room’ shall apply when the service is provided in a 24-hour facility, including a hospital outpatient department.


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)



• Crisis Stabilization-Urgent Care

• Crisis Stabilization-Urgent Care follows the same guidelines as ‘Crisis Stabilization: Emergency Room’ except that the maximum allowance for this category shall apply when the service is provided at an appropriate site other than an emergency room(citation: DHCS. (2013), Mental Health Medi-Cal Billing Manual)


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)



• BHS Policy Update-Crisis Stabilization Progress Notes

• One progress note per 23/hour period (per DHCS’ Annual Chart Review Protocol);

• PRIOR GUIDANCE: In the past (November 2017 – November 2018), BHS’ guidance was “one progress note per 4-hour block.”

• Medical necessity standard for Crisis Stabilization is same for other outpatient SMHS (i.e., significantly reduced a significant impairment)


Hours

9am

10am

11am

12pm

1pm

2pm

3pm

4pm

5pm

Day

Treatment

Rehab

(3hrs

minimum)

Day

Treatment

Intensive

(4hrs

minimum)

Monday

Crisis

Stabilization

(<24hrs)



• Services Billed in Days

• The following services are documented, billed and claimed in days:

• Adult Residential Services

• Crisis Residential Treatment Services

• Remember—these services are provided by Social Rehabilitation Programs


• Adult Residential Treatment Services

• “Adult Residential Treatment Service” means rehabilitative

services, provided in a non-institutional, residential setting, for

beneficiaries who would be at risk of hospitalization or other

institutional placement if they were not in the residential

treatment program. The service includes a range of activities

and services that support beneficiaries in their efforts to

restore, maintain and apply interpersonal and independent

living skills and to access community support systems. The

service is available 24 hours a day, seven days a week. Service

activities may include but are not limited to assessment, plan

development, therapy, rehabilitation and collateral” (Source: CCR,

Title 9, §1810.203)




• “Adult residential treatment services assist the beneficiary in

developing a personal community support system to substitute for

the program's supportive environment and to minimize the risk of

hospitalization and enhance the capability of independent living

upon discharge from the program. The program will also provide a

therapeutic environment in which beneficiaries are supported in their

efforts to acquire and apply interpersonal and independent living

skills…” (Source: CA State Plan Amendment 12-025)



• Adult Residential Treatment Services (cont.)

• “…and [Adult Residential Treatment Services include…]”

• Individual and group counseling;

• Crisis intervention such as counseling focusing on immediate problem solving in response to a

critical emotional incident to augment the beneficiary's usual coping mechanisms;

• Family counseling with significant support persons, when indicated in the client's

treatment/rehabilitation plan;

• The development of community support systems for beneficiaries to maximize their utilization of

non-mental health community resources;

• Counseling focused on reducing mental health symptoms and functional impairments to assist

beneficiaries to maximize their ability to obtain and retain pre-vocational or vocational

employment;

• Assisting beneficiaries to develop self-advocacy skills through observation, coaching, and

modeling;

• An activity program that encourages socialization within the program and general community,

and which links the beneficiary to resources which are available after leaving the program; and,

• Use of the residential environment to assist beneficiaries in the acquisition, testing, and/or

refinement of community living and interpersonal skills (Source: CA State Plan Amendment 12-025)




• Documentation: BHS Policy Update

• “Service Week” operationalized

• Sunday (12:00am) through Saturday (11:59pm)

• Weekly Summary Documentation & Timeliness

• Best practice is weekly summary fully finalized within 24hr of close of week (must include “Late Entry” if not completed within 5 business days of end of standard week)




• Documentation: BHS Policy Update-continued

• OPTIONAL ALTERNATIVE: seven consecutive daily notes can meet the documentation standard. The following must be true:

• Standard “Service Week”: documentation follows a standard “service week” where 7 days are defined as Sunday (12:00am) through Saturday (11:59pm)

• Daily Notes Written by End of Shift: for timeliness, the daily note must be completed by the end of the staff person’s shift

• Record Review and Audit Liability: if a single Daily Note is missing from the medical record during a record review/audit, then the complete service week for that missing note will be disallowed

• Daily Note LATE ENTRY: if the Daily Note is not fully finalized with required co-signature within 5 business days from the date of service, the documentation will be required to include [LATE ENTRY]




• Clinical Documentation Support Tool:





Key Element of

Adult

Residential

Details from Title 9, State Plan Amendment & BHS

Purpose of the

service

• Reduce functional impairments caused by mental disorder

• Restore, maintain and apply interpersonal and independent living skills

• Access community support systems

Target

population

• Beneficiaries at-risk of hospitalization

• Beneficiaries at-risk of institutional placement

Mechanism of

change

• Help client develop a personal community support system as a substitute for formal

program services

• Provide a therapeutic environment that supports a client to acquire and apply

interpersonal skills and independent living skills

Included

services

• Assessment, plan development, therapy, rehabilitation & collateral

• Counseling (individual, group, family)

• Development of skills (self-advocacy skills) through observation, coaching and modeling



• “…therapeutic or rehabilitative services provided in a non-

institutional residential setting which provides a structured

program as an alternative to hospitalization for beneficiaries

experiencing an acute psychiatric episode or crisis who do

not have medical complications requiring nursing care. The

service includes a range of activities and services that support

beneficiaries in their efforts to restore, maintain, and apply

interpersonal and independent living skills, and to access

community support systems. The service is available 24 hours

a day, seven days a week. Service activities may include but are

not limited to assessment, plan development, therapy,

rehabilitation, collateral, and crisis intervention” (Source: CCR, Title 9,

§1810.208)




• Documentation

• Daily note is required

• Medical necessity standard for Crisis Residential is same for other outpatient SMHS (i.e., significantly reduced a significant impairment)

• Required elements for Crisis Residential are generally same as for other outpatient SMHS (obvious exceptions)



• DEEP DIVE: SMHS delivered in a Social Rehabilitation facility

• Organizations providing Adult Residential and Crisis Residential services receive oversight from two regulators: Community Care Licensing (Dept of Social Services) and Department of Health Care Services



• DEEP DIVE: Frequently Encountered Placement Jargon

176*https://www.dhcs.ca.gov/services/MH/Documents/ADV_2013_06_05b_Alts_Psy_%20Inst_Workgroup_Table.pd

caution!

ADUs and RFTs

represent both

the physical

placement as well as

a specific SMHS


• *Acute Diversion Unit (ADU):

• term used synonymously with “Crisis Residential”

• alternative to/diversion from hospital (or reduction of inpt hospital and post-hospital step-down

• *Residential Treatment Facility (RTF):

• Term used synonymously with “Transitional Residential”



• Residential Care Facilities (RCFs)**: non–medical facilities that provide room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring. This level of care and supervision is for people who are unable to live by themselves but who do not need 24 hour nursing care. Not required to have nurses, certified nursing assistants or doctors on staff. Residential care facilities are not allowed to provide skilled nursing services, such as give injections nor maintain catheters nor perform colostomy care (unless there is a credentialed RN or LVN individual working in the home)

• Adult Residential Facilities (ARFs)

• Residential Care Facilities for the Elderly (RCFEs; for 60yrs+)

177**https://www.dhcs.ca.gov/services/MH/Documents/ADV_2013_06_05b_Alts_Psy_%20Inst_Workgroup_Table.pd




• For San Francisco Health Network’s Transition Division (placement team)***:

• “Hotel” = Single Room Occupancy (SRO)

• “Board & Care” = RCF and ARF (18yrs-59yrs); RCFE (60yrs+)

• “Mental Health Rehabilitation Center” (MHRC) = Institute for Mental Disease (IMD) and Locked SubAcute Treatment (LSAT)

• “Locked Settings” = MHRC/IMD; also the “Neuro-Behavioral Skilled Nursing Facility (SNF)

178

***https://www.sfdph.org/dph/hc/HCCommPublHlth/Agendas/2017/June%2020/Transitions%20Overview%20to%20HC%2017-06%20DRAFT%20ver%20170614.pdf



• Service Lockouts

• Service lockout = situation/circumstance when federal financial participation (FFP) is not available for the specific SMHS.

• See these as logical inconsistencies!

• Example: My client is currently in a high-end placement (e.g., Adult Crisis Residential) and receiving services. I conduct a service activity while she is in Adult Crisis Residential (e.g., I speak with mother about concerns about how to support daughter’s safety).

• This is a service lockout—you cannot provide services to your client (i.e., conduct a collateral session) when you client is already receiving services!




• DHCS Billing Manual (2013):




• OLD EXAMPLE: Mapping SF Providers to Lockouts:


List of DHCS Services

(and Procedure Code) for

Service Lockouts

SFDPH-BHS Contractor (with Program Code) or Local Bay Area Provider

Inpatient Hospital

(H2015/H0046)

1. Dignity Health at St. Mary's (FFS Adolescent Inpt MH; also CYF-SEEP)

2. Dignitiy Health at St. Francis (FFS Adult Inpt MH)

3. John Muir Behavioral Health Center (FFS Inpt)

4. Langley Porter Psychiatric Institute (FFS Inpt)

5. San Francisco General Hospital (SD/MC Hospital)

Psychiatric Health Facility

(PHF)

(H2013)

1. Telecare Heritage Psychiatric Health Facility (Alameda County)

2. Crestwood Psychiatric Health Facility (Sacramento County)

Adult Crisis Residential

(H0018)

aka Acute Diversion Unit

1. Baker Places: Grove Street House (89781)

2. Progress Foundation: La Posada (38081/OP)

3. Progress Foundation: Shrader (89661/OP)

4. Progress Foundation: Avenues (38A41/38A43)

5. Progress Foundation: Dore House (38GM1/38GM3)

Adult Residential Treatment

(H0019)

aka Transitional

Residential Facility [RTF]

1. Baker Places: Baker St. House (38391/DT)

2. Baker Places: Robertson Place (38851/DT)

3. Baker Places: Jo Ruffin Place (89911/2)

4. Baker Places: San Jose Place (38BS1/2)

5. Progress Foundation: La Amistad (38091)

6. Progress Foundation: Progress (38371)

7. Progress Foundation: Courtland (38631)

8. Progress Foundation: Clay Street (89851)

9. Progress Foundation: Dorine Loso House (38GH1)

10. Progress Foundation: Ashbury House (89841)

11. Progress Foundation: Carroll House (38541)

12. Progress Foundation: Rypins House (38531)

Chapter 8:

Special Topics:Insights from DHCS (2015 & 2017)


8: Insights from DHCS (2015)

• “Safety Net Services” vs. “Medicaid-Reimbursable Services”

• Public Health Agencies: State laws require public health agencies to prioritize services and efforts toward particular populations

• Our Welfare & Institutions Code (W&I Code) defines and provides criteria for “Serious Mental Disorder” adults “Seriously Emotionally Disturbed” children [W&I § 5600.3(a) and 5600.3(b) respectively].

• Managed Care Entities: contracts and laws require managed care entities (or similar entities) to pay for services if they are medically necessary.

• Just because your client has been labelled “SMI” or “SED” does not mean that your client meets medical necessity for SMHS



• Diagnosis

• “Covered/Included” Diagnoses for Non-Hospital SMHS & Personality Disorders includes personality disorders (with the exception of Antisocial Personality Disorder)

• “Personality disorder categories may be applied with children or adolescents in those relatively unusual instances in which the individual's particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or another mental disorder. It should be recognized that the traits of a personality disorder that appear in childhood will often not persist unchanged into adult life. For a personality disorder to be diagnosed in an individual younger than 18 years, the features must have been present for at least 1 year. The one exception to this is antisocial personality disorder, which cannot be diagnosed in individuals younger than 18 years. Although, by definition, a personality disorder requires an onset no later than early adulthood, individuals may not come to clinical attention until relatively late in life” (DSM-5, ps 647-648).




Excluded Diagnoses for Outpatient SMHS

“Deferred” or “by history” Communication Disorders Autism Spectrum Disorder

A stand-alone “Rule Out”

diagnosis

Delirium Tic Disorders

Provisional Diagnosis (either

depression or bipolar)

Dementia Cognitive Disorders (e.g.,

dementia with depressed

mood)

“V” codes Amnestic Disorders Substance-Induced Disorders

Mental Retardation (aka

Intellectual Disabilities)

Sleep Disorders Intermittent Explosive Disorder

Learning Disorders Mental Disorders due to a

General Medical Condition

Pyromania

Motor Skill Disorders Other condition that May be a

Focus of Clinical Attention

Antisocial Personality Disorder


• Diagnosis



• Assessment



• Standards for Client Plan Interventions:

• “Expectation that interventions significantly diminish or prevent significant deterioration…”

• DHCS’ Expectations = “Reasonable Mental Health Professional”

• “Would a reasonable mental health professional (using

community standards of care) expect that your intervention

would cause a significant diminishment of a functional

impairment (or prevent significant deterioration in

functioning)?”



• Standards for Client Plan Interventions:

• “…the type of intervention/modality including a detailed description of the intervention to be provided”

189

Modality Intervention Written Example of Detailed Description

TherapyCognitive

Reframing

Intervention #1: Therapy (including CBT interventions of cognitive reframing, pleasant

activity scheduling and exposure) to improve client’s Vocational and Social impairments.

Will occur weekly, for 50mins by…

RehabilitationBehavioral

Modeling

Intervention #2: Rehabilitation (including behavioral modeling and social skills training)

to improve client’s Social impairments. Will occur every other week for 30mins by…

Collateral

Psychoed &

Family

Counseling

Intervention #3: Collateral to client’s mother (including psychoeducation on episodic

schizophrenia) and family counseling with mother and client (developing a mutually

agreed plan for mother to support son’s treatment) to address Vocational and Social

Impairments. Will occur weekly for 40mins by…

Targeted Care

ManagementBrokerage

Intervention #4: TCM for client (specifically, brokerage and service monitoring) to access

Supported Vocational Program. Will occur weekly for 15mins by…

Medication

Support

Prescribing

& Monitoring

Intervention #5: Medication Support to client (including prescribing and monitoring) to

alleviate symptoms of Schizophrenia and improve Social and Vocational functioning. Will

occur every other week for 20mins by…San Francisco Mental Health Plan (Nov/Dec 2018)


• Treatment Plan of Care?



• Signatures on Assessments vs. TPOCs?

• Legal Documents:

• Informed Consent: the signature identifies the person who may legally provide consent for treatment (e.g., juvenile dependency court; conservatorship).

• Release of Information: the signature identifies the person who may legally control the personal health information (PHI).

• “Full Disclosure” Documents:

• Medication Consent: the signature demonstrates the client has been advised of risks/benefits (even for dosage change!).



• Signatures on Assessments vs. TPOCs?

• Assessment Form:

• LPHA signature/date confirms the mental status exam and differential diagnosis was conducted by a staff member with the appropriate scope of practice.

• Client Plan:

• LPHA signature/date confirms that treatment interventions are expected to significantly reduce/prevent significant decline in functioning.

• Client signature/date confirms that the client participated in and agrees with the Client Plan.



• Services & Progress Notes (Best Practices)

• Clear, concise and succinct;

• Interventions are clearly linked to mental health functional impairments and included diagnosis;

• Client response to intervention is described:

• When you provided the intervention, what was the response?

• If services are provided in the home, document why community-based services need to be offered to the client.



• Services & Progress Notes (Family Counseling vs. Family Therapy)

• Collateral (Family Counseling) vs. Therapy (provided as Family Therapy)?

• What is the focus of treatment—this is the key variable to consider!

• Collateral = focus on the needs of the client in meeting the goals of their Client Plan

• Family Therapy = focus is family system (as a whole) and what goes on between individuals in the family



• Services & Progress Notes (Case Conferences)

• Document your contribution in the meeting (vs. listening).

• Document the time you participated in the meeting (vs. claiming the entire meeting).

• The progress note must meet medical necessity criteria!



• Services & Progress Notes



• Activities Not Billable to MH Medi-Cal:

• Solely clerical activities (e.g., faxing, filling out applications, leaving a voicemail)

• Non-clinical review of charts or other paperwork (e.g., utilization review, chart auditing, prep for supervision)

• Filling out SSI forms, APS/CPS reports and other non-TCM related activities

• Grocery store trips that do not include skills training or other linkage to functional impairments

• No shows

• Supervision



• Activities Not Billable to MH Medi-Cal (cont..):

• Solely payee related activities

• Staff provides a service that is not in their scope of practice.

• An LCSW/PhD, etc. can talk with a client about medication compliance (e.g., barriers), but cannot assess side effects, the need for new meds, etc.

• Progress notes that have been “cloned” (i.e., copied/pasted and not individualized to client’s functional impairments).




• Transportation (vs. Billable Travel)

• If you must provide a service in the community (client’s home, school, work, park, etc.), you will document the amount of time it takes to drive from your office to the community and return to the office.

• “Service time” in Mental Health Medi-Cal SMSH = (Face-to-Face Time) + (Documentation Time) + (Travel Time)

• In contrast, transporting a client is not a billable service (e.g., taking them to a doctor’s appointment).




• Transportation (vs. Billable Travel)—continued

• Document the client’s mental health need that requires you to travel into the community (e.g., “client cannot access mental health services at office due to symptoms of agoraphobia”…”client does not have a car and does not have reliable access to mass transportation”…)

• Consider adding the client’s transportation barriers to your treatment plan—your client needs to be able to access services!



• Cultural & Linguistic Requirements:

• Mental health interpreter services must be offered and provided.

• Refusal to accept interpreter services must be documented in the medical record.

• When applicable, information must be provided to clients in an alternative format (e.g., large font; audio).

• Service-related correspondence = preferred language



• Cultural & Linguistic Requirements (cont..):

• Title VI of the Civil Rights Act of 1964:

• Prohibits the expectation that family members provide interpreter services and minors should not be used as interpreters.

• A client may choose to use a family member/friend as an interpreter after being informed of the availability of free interpreter services.

• In some cases, it may be necessary to use a family member or minor for interpretation services (e.g., a paranoid client refuses to talk to anyone but the minor child). In these instances, the justification should be documented.


Wrapping Up…

• Questions and Thoughts?


Mental Health Medi-Cal Clinical Documentation …...Chapters in this Training Curricula San...

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