for the Right Client at the Right Time February 2017 1 Referral Process Referral Management Process through KEPRO for ITRT Intensive Temporary Residential Treatment HCT Section 65 Home and Community Based Treatment ID: 690559
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Slide1
Choosing the
Right Service for the Right Client at the Right Time February 2017
1Slide2
Referral Process
Referral Management Process through KEPRO for:(ITRT) Intensive Temporary Residential Treatment(HCT) Section 65 Home and Community Based Treatment(RCS 28) Section 28 Rehabilitation and Community Support
(MST & MST-PSB) Multi-systemic Therapy – Problem Sexual Behavior
(FFT) Functional Family Therapy
2Slide3
Role of Case Manager
The Case Manager is one of the major gateways through which Mainecare clients enter the CBHS system of care. The system depends on CMs to:Engage in often chaotic family systems with high anxiety and stress levelsMake thorough assessments of the needs and strengths of clients and familiesBe knowledgeable of community services or know where to find them.Understand what issues each service is meant to treat or address
Understand the referral process for which the referrals flow
Because of the complexity of the system and staff attrition in Case Management, ongoing training and communication is required in the system at the State level and within the individual agencies.
The purpose of this training is to contribute to this learning process….
3Slide4
Role of Case Manager
(Cont.)Some Clarifications on common issues to be aware of:Being careful that the CMs assessment drives the service referrals and not the anxiety and stress level of the family:Often the family is desperate for help and the CM may feel pressure to simply begin referring to many services before they have been able to gather a sense of the family needs. This can lead to referrals for services that will not adequately meet the client need, treatment failure, client and provider frustration, and increased intensity of the need not being addressed.
Incorrectly referring clients with “Mental Health” needs (e.g
. ADHD, Anxiety,
Trauma) to a non-mental health service such as RCS 28:
Although many DD/ID and MH clients may possess functional limitations, the etiology of the functioning deficit is likely different and requires a different intervention. Out-patient or HCT is typically more appropriate for Mental Health based functional deficits.
The “Monitoring” function of CM is an
active
process:
This has led to numerous service denials and frustrations in the system. Monitoring is a active/action-based service component and it must be articulated as such. Calling providers for follow-up, meeting with clients and providers to see if the interventions remain effective, etc.…are all monitoring functions if they are for the purpose of maintaining forward progress on IPC goals.
4Slide5
Referral Role of
Case Manager13.02 Comprehensive Assessment and Periodic Re-assessment of an eligible member to determine service needs, including those activities that focus on needs identification, to determine the need for any medical, educational, social or other services. The comprehensive assessment and re-assessment must be conducted through face-to-face contact with the member and, where appropriate, consultation with other providers and with the member's family.
What is the need?How active can family be in treatment?
What is/are the appropriately assessed service(s)?
What is plan if the service(s) is/are not available?
Referral
activity
for case
management
is
completed once the referral and linkage has been made.
Monitoring and Follow-Up Activities
(
Monitoring is an ACTIVE process
)
that includes
activities and contacts that are necessary to ensure that the Individual Plan of Care is effectively implemented and adequately addresses the needs of the eligible memberIs member on the Referral Management list?Has members demographics changed that will effect service?Has there been a change in providers?Has there been a change in need so that family no longer requests the services or if member is now a priority for services?
5Slide6
(ITRT) Section
97 ITRT must be provided in the least restrictive environment possible.Placement should be as close to the child’s home as possible. Families must remain as actively involved
as possible in their child’s care and treatment.
The purposes of ITRT
is to
provide all
required services
to both treat the mental illness/disorder and to return the child to his/her family, home and community as soon as possible
.
Documentation to support ITRT should be within the past 60 days
ONLY.
6Slide7
(ITRT) Mental
Retardation and Pervasive Developmental Disorder (PDD) ConditionsBasic Criteria for
all (ID/DD):
All
of the following criteria set forth below must be met, in addition to criteria for either Level I or Level II services, as detailed below.
The
child must have:
An Axis I or II diagnosis from the most current version of the
DSM and;
A
disorder that has lasted for at least six (6) months or is expected to last for at least one (1) year in the future,
and
A
current need for therapeutic treatment or availability of a therapeutic on-site staff response on a twenty-four hour basis,
and
A
disorder that is amenable to treatment in a residential setting,
andEven with intensive community intervention, including services and supports, there is significant potential that the child will be hospitalized, or there is a clear indication that the child’s condition would significantly deteriorate and would require a higher model of service than can be provided in the home and community
.
In addition to the above criteria, the child must meet the following criteria for either Level I or Level II services:
7Slide8
(ITRT) Mental Retardation and
Pervasive Developmental Disorder (PDD) Conditions (Cont.)Level I Criteria (ID/DD)
Significant recent aggression across multiple environments or severe enough within one environment to have caused serious injury or there is significant potential of serious injury to self or others; or
Recent homicidal ideation with risk of harm to others, or
Recent suicidal ideation with risk of harm to self; or
Symptoms of mental retardation
(Intellectual Disability) or
Pervasive Developmental Disorder so severe that it results in an inability to care for oneself to a developmentally appropriate level even with home and community supports and services; or
Has not responded to less restrictive level of care or would have a significant risk of harm to self or others if a less restrictive setting were attempted; and
An assessment using the Children’s Habilitation Assessment Tool (CHAT) with a score of 30 or
higher
or Global Assessment Functioning (GAF) tool score of 50 or lower with description of specific
symptoms
justifying the score.
8Slide9
(ITRT) Mental Retardation and
Pervasive Developmental Disorder (PDD) Conditions (Cont.)Level II Criteria (ID/DD)
The Child must meet all the level I service criteria and in
addition…
Frequency, intensity and duration of intervention required to address daily repeated aggression and potential for harm to self or others, or
Frequency, intensity and duration of assistance required to address activities of daily living and potential for harm to self or others either directly or as a consequence of being unable to maintain ADL’s and
Children’s Habilitation Assessment Tool (CHAT) score of 35 or higher, or a Global Assessment Functioning (GAF) score of 40 or lower with description of specific symptoms justifying the score
.
9Slide10
(ITRT) Child Mental Health
ConditionsBasic Criteria for all (MH):All of the following criteria set forth below must be met, in addition to criteria for either Level I or Level II services, as detailed below. The child must have:
The
child must have either an Axis I or II diagnosis from the most current version of the DSM, and
The
child’s disorder has lasted for at least six (6) months or is expected to last for at least one year in the future, and
The
child has a current need for therapeutic treatment or availability of a therapeutic on-site staff response on a twenty-four hour basis, and
The
child’s disorder is amenable to treatment in a residential setting, and
Even
with intensive community intervention, including services and supports, there is significant potential that the child will be hospitalized, or there is a clear indication that the child’s condition would significantly deteriorate and would require a higher model of service than can be provided in the home and community
.
In addition, the child must meet the criteria below for Level I or Level II services:
10Slide11
(ITRT) Child Mental Health
Conditions (Cont.)Level I Criteria (MH)
Significant
recent aggression across multiple environments or severe enough within one environment to have caused injury or there is significant potential of injury to self or others; or
Recent
homicidal ideation with risk of harm to others, or
Recent
suicidal ideation with risk of harm to self; or
Symptoms
of mental illness so severe that it results in an inability to care for oneself in a developmentally appropriate manner, even with home and community supports or services; or
Has
not responded to less restrictive model of service or would have a significant risk of harm to self or others if a less restrictive setting were attempted; and
A
Child and Adolescent Functional Assessment Scale (CAFAS) score of 100 or higher or Global Assessment Functioning (GAF) score of 50 or lower with description of specific symptoms justifying the score.
11Slide12
(ITRT) Child Mental Health
Conditions (Cont.)Level II Criteria
(MH)
Frequency
, intensity and duration of intervention required to address daily repeated aggression and potential for harm to self or others, or
Frequency
, intensity and duration of assistance required to address Activities of Daily Living and potential for harm to self or others either directly or as a consequence of being unable to maintain ADL’s and
A
Child and Adolescent Functional Assessment Scale (CAFAS) 8 scale score of 120 or higher, or Global Assessment Functioning (GAF) score of 40 or lower with description of specific symptoms justifying the score.
12Slide13
(RCS 28) REHABILITATIVE
AND COMMUNITY SUPPORT SERVICES Completed DSM
or DC-03
diagnosis and;
Have
a functional assessment administered within one (1) year prior to the date of the referral documenting functional impairment measured as two (2) standard deviations below the mean on the composite score or have one point five (1.5) standard deviations below the mean on the composite score and two standard deviations below the mean in the communication or social domain sub score of the most current version of the
Vineland
Adaptive
Behavior
or
The Adaptive Behavioral Assessment Scales ABAS
or
Have
a functional assessment administered within one (1) year prior to the date of the referral documenting functional impairment measured as two (2) standard deviations below the mean on the Developmental Quotient of the
Battelle
Developmental Inventory or have 1.5 standard deviations below the mean on the Developmental Quotient and two (2) standard deviations below the mean on in the Personal-Social, Adaptive, Communication, or Cognitive
subscales, or
Have
a functional assessment administered within one (1) year prior to the date of the referral documenting functional impairment measured as two (2) standard deviations below the mean on the composite Adaptive Score of the
Bayley Scales
of Infant and Toddler Development or have 1.5 standard deviations below the mean on the composite Adaptive Score and two (2) standard deviations below the mean on the Social or Communication domain or Cognitive, Language or Social Emotional
Subscale, or
Other
functionally equivalent tools approved by DHHS and other clinical assessment information obtained from the member and family; OR
13Slide14
(RCS 28) REHABILITATIVE AND
COMMUNITY SUPPORT SERVICES (Cont.)A
member aged birth through five (5) years, who has a diagnosis from a physician (including psychiatrist) of a specific congenital or acquired condition, and a written assessment by a physician (including psychiatrist) that there is a significant probability that because of that condition, the member will meet the functional impairment criteria in (C)(1) above, later in life if medically necessary services and supports are not provided to the member;
Family
Participation is required in treatment services to the greatest degree possible given the individual needs as well as family
circumstances
(Vineland)
Adaptive Behavior:
http
://
psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=Vineland-II
(ABAS) The
Adaptive Behavioral Assessment Scales
:
http
://
www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8004-507&Mode=summary
Battelle Developmental Inventory
http://www.riverpub.com/products/bdi2/index.html
Bayley
Scales of Infant and Toddler Development
http
://www.pearsonassessments.com/haiweb/cultures/en-us/productdetail.htm?pid=015-8027-264
14Slide15
(
HCT) Section 65 Home and Community Treatment ServicesThis treatment is for members in need of mental health treatment based in the Home and Community (excluding school settings) who need a higher intensity service than Outpatient but a lower intensity than Children’s ACT.
The services assist the member and parent or caregiver to
understand the member’s behavior and developmental level
including co-occurring mental health and substance abuse,
teaching the member and family or caregiver
how to appropriately and therapeutically respond to the member’s identified treatment needs,
supporting and improving effective communication
between the parent or caregiver and the member,
facilitating appropriate collaboration
between the parent or caregiver and the member, and
developing plans
and strategies with the member and parent or caregiver to improve and manage the member’s and/or family’s future functioning in the home and community
.
Services include therapy, counseling or problem-solving activities in order to help the member develop and maintain skills and abilities necessary to manage his or her mental health treatment needs, learning the social skills and behaviors necessary to live with and interact with the community members and independently, and to build or maintain satisfactory relationships with peers or adults, learning the skills that will improve a member's self-awareness, environmental awareness, social appropriateness and support social integration, and learning awareness of and appropriate use of community services and resources
15Slide16
(HCT) General
Eligibility RequirementsHave a medically necessary need for the service, defined as follows:
DSM or DC-03 diagnosis within
thirty (30) days of the start of service.
Excludes, the
following: Learning Disabilities (LD) in reading, mathematics, written expression, Motor Skills Disorder, and LD NOS (Learning Disabilities Not Otherwise
Specified), Communication
Disorders (Expressive Language Disorders, Mixed Receptive Expressive Language Disorder, Phonological Disorder, Stuttering, and Communication Disorder NOS);
and
Have a significant functional impairment (defined as a substantial interference with or limitation of a member’s achievement or maintenance of one or more developmentally appropriate, social, behavioral, cognitive, or adaptive skills),
and
Have a diagnosis of a serious emotional disturbance for one (1) year or likely to last more than one (1) year;
and
Determination of the appropriate level of care based on the Child/ Adolescent’s Level of Functional Assessment
Score
(CAFAS
) or Preschool and Early Childhood Functional Assessment Scale (PECFAS),
(CAFAS/PECFAS no longer required
)
other tools
(YOQ) approved
by DHHS and other clinical assessment information obtained from the member and family;
(later in 2017, CANS will be approved tool to replace the YOQ)
and
Need treatment that is more intensive and frequent than what he or she would get in Outpatient and a lower intensity than Children’s ACT;
and
If the member is living with the parent or guardian the parent/guardian must participate in the member’s treatment, consistent with the ITP.
16Slide17
HCT Referral Management Process
See Referral Management Flow Chart:http://www.qualitycareforme.com/media/1657/ref-managment-flow.pdf 17Slide18
MST /
MST-PSB / FFT Referral Information Multisystemic Therapy (MST)Multisystemic Therapy - Problem Sexual Behavior (MST-PSB)Functional Family Therapy (FFT)It’s important to consider whether MST, MST-PSB, or FFT may be appropriate for your clients. Often times client’s who may be well served in these Evidence-based practices are referred directly to HCT instead.
18Slide19
MST /
MST-PSB / FFT Referral Information Multisystemic Therapy (MST)Here are a few basic eligibility requirements for MST:Ages 10-17.5Physical aggression at home or school
Externalizing behavior resulting in diagnosis of Conduct Disorder or other Disruptive Behavior disordersCriminal or delinquent behaviorRisk of Out of Home placement
Multiple system involvement
Verbal aggression or verbal threats
19Slide20
MST /
MST-PSB / FFT Referral Information Multisystemic Therapy - Problem Sexual Behavior (MST-PSB)Here are a few basic eligibility requirements for MST-PSB:Ages 11-17.5
Has been engaged in sexually assaultive behavior with another person
20Slide21
MST /
MST-PSB / FFT Referral Information Functional Family Therapy (FFT)Here are a few basic eligibility requirements for FFT:Ages 11-18 with at least one parent to participate in treatment
Youth residing within Androscoggin, Sagadahoc, Kennebec, Lincoln, Somerset (up to Solon), Penobscot (to Lagrange), and Hancock counties.Conduct problems including violence or aggression
Discharging from Out of Home Placement
DOC involvement
21Slide22
MST /
MST-PSB / FFT Referral Information Multisystemic Therapy (MST)Multisystemic Therapy - Problem Sexual Behavior (MST-PSB)Functional Family Therapy (FFT)See additional attachments at the link below for these services:
http
://
www.maine.gov/dhhs/ocfs/cbhs/provider/training.html?utm_medium=email&utm_source=govdelivery
22Slide23
Contact For Service Notification
(CFSN) for Referral ManagementHow to Submit a Contact for Service Notification (CFSN) in CareConnection®
For Members With an
active MaineCare
number
Begin
the CFSN on the “New Request” page. Enter in
the
MaineCare number in the “Member ID” box.
Enter
in one other piece of identifying
information.
Click “Verify” and then click “Add Member.”
23Slide24
Contact For Service Notification
(CFSN) for Referral ManagementThe Member Information Page - This page will auto-populate for members with a MaineCare number. You
are not able to edit this information
, as it is a
direct
feed from MaineCare. Click “Save and
Continue.”
24Slide25
Contact For Service Notification
(CFSN) for Referral Management3. Guardian Information Page - Please complete this
page for children and for adults who are under guardianship
. Click “Save and Continue.”
25Slide26
Contact For Service Notification
(CFSN) for Referral Management4. Administrative Page – Choose
“Contact For Service Notification” for the “Authorization
Type.”
The
“Start Date for Current Authorization Request”
must
be the date of the member’s first contact
for
service.
Choose
“Routine” in the dropdown menu for “This
Request
is.” Choose
the appropriate “Review Type” and “Category
of
Service.” For ITRT select ITRT ReferralFor Section 28 select Rehab and Community Support Services – Section 28For HCT select Child
and Family Behavioral Health Treatment (Community
Based)
The
“Date of Referral” is the date the member was first referred to your agency.
Select
the “Location at Time of Referral”
Click
“Save and Continue.”
26Slide27
Contact For Service Notification
(CFSN) for Referral ManagementRequesting Agency Page - Fill out all of the sections
in red, and click “Yes” for “Is this agency/individual the
treating
provider?” Click “Save and
Continue
27Slide28
Contact For Service Notification
(CFSN) for Referral ManagementServices Requested Page – Click on the “Add New Procedure Request” link. Choose the procedure code for the appropriate service.
For ITRT select 100-219 Section 97 ITRT Eligibility Determination
Fir Section 28
select
100-219 Section 28 Eligibility Determination – OCFS Provider’s Non-Specialized
or 100-219 Section 28 Eligibility Determination – OCFS Provider’s Specialized
For HCT
select
100-219 Section 65 Eligibility Determination – OCFS Provider
Choose the “Frequency of Services”.
Choose the “Provider Billing ID”.
Your service length and units will automatically populate. You may generate the end date automatically by clicking in the “Service Length” box and hitting the Tab key on your keyboard. Click “Save” to add the service code.
Click “Save and Continue”.
28Slide29
General Instructions:
Contact For Service Notification (CFSN) for Referral ManagementTreatment Plan Page – In the comment text box, please include the reason for referral, copied from the Section 28 and Section 65 referral form.
Additional Information
- For
65 and 28
PLEASE ONLY USE THIS BOX FOR THIS INFORMATION:
Referral source: Name, number, email address
PREFERRED PROVIDER:___________________
PLEASE DO NOT SEND:_________________________________
For
ITRT Referral, please use the ITRT submission guide.
Document Upload Page
– Please upload the application/referral and appropriate documents.
Click “Document Type” and select the appropriate document from the dropdown
Click “Browse” and find the document on your computer
Click “Attach”
Complete steps a-c for each document you need to upload
29Slide30
Contact For Service Notification
(CFSN) for Referral Management10. Submit to KEPRO Page – Click the blue “Submit to KEPRO” button to submit your CFSN.
30Slide31
Contact For Service Notification
(CFSN) for Referral ManagementRemoving a Member from a Referral ListIf the member is removed from the providers’ referral list
without starting services, the provider will discharge the appropriate Contact for Service Notification
.
When the member is assigned to the providers’ service
,
a Prior Authorization request is submitted. This will remove the member from the referral list report. The Contact for service Notification does not need to be discharged
.
31Slide32
After Referral Has Been Submitted…
Family is notified of approval and denials of any referralProvider can access approvals through CareConnection when they submit a CFSN. Approvals can be used to verify referral has been submitted and approved through KEPRO.Provider will receive a letter of denial if referral is not approved
Does family still need service?
Is guardian still willing to participate in active service?
Has family moved? Update MaineCare and KEPRO
Has Guardian changed? Update MaineCare and KEPRO
Is guardian will to take first available provider versus a family choice provider now?
32Slide33
Provider List
Below is the link to the OCFS provider listing. OCFS Staff update this information regularly when providers notify OCFS of changes. http://www.maine.gov/dhhs/ocfs/cbhs/provider-list/home.html
33Slide34
End
Questions and Discussion34