Crisis Services Redesign Implementation Overview for LMHA’s Presenter: Mike Maples, Director MHSA

Crisis Services RedesignImplementation Overview for LMHA’sPresenter: Mike Maples, Director MHSA

In December 2005, then Commissioner of Texas Department of State Health Services (DSHS), Eduardo Sanchez established the Crisis Services Redesign Committee to develop recommendations for mental health and substance abuses crisis services that are delivered throughout the local mental health authorities in the State of Texas.

Overview

The charge to the Crisis Redesign Committee and the purpose of redesign was to develop recommendations for a comprehensive array of specific services that will best meet the needs of Texans who are having a mental health and/or substance abuse crisis.

Purpose of Redesign

A consistent state of the art system of crisis services across Texas

with improved:

Accessibility Standards of care Community involvement Consumer choice Less restrictive treatment environments Lessening burden on hospitals, jails &

law enforcement

Goals of Crisis Redesign

This committee was formed with representation from:

The recommendations from this group are guiding the course for Crisis Redesign now in it’s Implementation Phase.

Crisis Services Redesign Committee

NAMI Advocacy Groups State and Private

Hospitals Mental Health

professionals Mental support

groups and prevention groups

Physicians Law Enforcement and

Judiciary DSHS Community Mental

Health Centers

REQUESTED: DSHS requested $82 million from the 80th Legislature to make significant progress toward improving the response to behavioral health crises.

AWARDED: Through the Legislature and Rider 69, the full $82 million was granted over fiscal years 2008/ 2009 to redesign and improve the mental health crisis system across Texas.

Crisis Services Funding

$27.3 million will be allocated in FY 08

$54.7 million will be allocated in FY 09

Additional funds will be requested from the 81st Legislature

It is required that new crisis redesign general revenue funds will be used to improve crisis services provided and not replace the current crisis services.

Crisis Services Funding, cont.

Consistent with the proposed use of funds described in the Legislative Appropriation Request (LAR), the new crisis funds will be divided into five portions: EQUITY PROPORTIONAL COMMUNITY INVESTMENT INCENTIVE COMPETENCY RESTORATION

ALLOCATION STATE EXPENDITURES

Allocation of Funds

To address inequities that have developed over time among funding for LMHA’s

Allocates 32% (approximately $27million) to bring under-funded LMHAs up to the current state average of per capita funding

Equity

Allocates 36% (almost $30 million) to be divided proportionally. However under this simple per capita distribution, many Centers would not receive sufficient dollars to allow full implementation of initial services. Thus DSHS will first assure that all Centers receive enough funding to for Crisis Hotline and Mobile Crisis Outreach Teams (MCOTs) and then will divide the remaining funds on a per capita basis.

Proportional

Additionally, there will be community investment incentive funds which will allow LMHAs (including NorthStar) or groups of LMHAs who provide 25% local match to compete for extra dollars to create the following: Psychiatric Emergency Service Centers (PESCs) Projects for jail diversion or alternatives to

State hospitalization

Community Incentive

$3 Million over the FY08-09 biennium will be available to LMHAs including NorthStar

LMHAs and NorthStar may apply for these additional funds to provide outpatient competency restoration services to individuals who are incompetent to stand trial but are eligible to receive mental health outpatient treatment

Competency Restoration Funds

1.5% or about 1.2 million will be used by DSHS to support the crisis redesign initiative over the biennium including: Hotline training by AAS (American

Association of Suicidology) Four DSHS staff positions An independent evaluation of the project at a

later date

State Expenditures

Crisis Services StandardsPresenter: Jennifer Edwards, DSHSCommunity MHSA Program Services Section

DSHS has promulgated Standards for all services in the crisis service array. Standards address:

Description of service What acuity is served in each service Plant/facility requirements Staff credentials and training requirements Assessment parameters Services provided and time frames for delivery Continuity of care

Crisis Services Standards

Every LMHA will be required to provide a continuously available telephone hotline staffed by trained hotline workers who provide information, screening and assessment, intervention and support to callers 24 hours per day, 7 days per week.

What’s new about hotline?

Hotlines must be accredited by the American Association of Suicidology (AAS)

Thorough training and adherence to standards will ensure consistency

Initial Crisis Services: Hotline

The American Association of Suicidology (AAS) was selected by DSHS as the accrediting body for hotlines across the state. Their curriculum involves extensive training and demonstration of competency.

Two key training objectives: Immediate access to quality hotline training Development of a sustainable training

infrastructure

Crisis Hotline Training

DSHS will host four regional AAS hotline training events in FY 08:

DallasHoustonAustinCorpus Christi

Two tracks will be provided—three days for hotline workers and two additional days for Train-the-Trainer

Crisis Hotline Training, cont.

Trainers completing the Train-the-Trainer course may train other hotline workers for the future

Additional DSHS staff will become certified trainers and will be available to provide future training

Crisis Hotline Training, cont.

Mobile Crisis Outreach Teams provide a combination of crisis services including emergency care, urgent care, and crisis follow-up and relapse prevention to the child, adolescent, or adult in the community.

Initial Crisis Services:Mobile Crisis Outreach

Teams

What’s new about

Mobile Outreach?

Greater accessibility to Mobile Crisis Outreach Teams (MCOTs)

Specific MCOT Standards regarding delivery of services and training & experience required of MCOT Staff

Mobile Crisis Outreach

Staffing Patterns: Availability 24/7 in all communities

Urban LMHAs: Minimum of one MCOT on duty during LMHA-designated “peak hours” totaling 84 hours per week

One additional Urban MCOT on call 24/7

Rural LMHAs: One MCOT on duty during LMHA-designated “peak hours” totaling 56 hours per week

MCOT capability is maintained throughout the Local Service Area (LSA) 24/7

Mobile Crisis Outreach Teams

Not every county in the LSA needs an MCOT; however the ability to meet face-to-face within one hour remains a Community Standard

Team Composition: A MCOT, at a minimum, is comprised of 2 QMHP-CSs or where appropriate, 1 QMHP-CS and law enforcement

Urban LMHAs: QMHP-CS is deployed with an RN, LPHA, or physician, preferably a psychiatrist, on every emergent care call


Rural LMHAs: It is recommended that a QMHP-CS is deployed with an RN, LPHA, or physician, preferably a psychiatrist. If not deployed as part of the MCOT, a physician, LPHA, or RN must be available to provide face-to-face assessment as needed or clinically indicated.

Location: MCOT services are designed to reach individuals in their place of residence, school, and/or other community-based safe locations

Services Provided: Crisis assessment, crisis intervention services, and crisis follow-up and relapse prevention


Initial Services to be Implemented:

Hotline Mobile Crisis Outreach Team

These are the initial services expected for implementation and adherence to standards.

Any remaining funds post-implementation of hotline and MCOT will be available to LMHAs to spend on “Enhanced Services”

Roll-out of Crisis Redesign

Crisis Outpatient Services

Extended Observation Services (up to 48 hours)

Crisis Stabilization Units (CSUs)

Crisis Residential (Child or Adult)

Crisis Respite (Child or Adult)

Mental Health Deputies/Crisis Intervention Teams

Transportation

Purchase of additional inpatient hospital beds

Enhanced Services

Crisis Outpatient Services: Office-based outpatient services for adults, children

and adolescents providing immediate screening and assessment and brief, intensive interventions focused on resolving a crisis and preventing admission to a more intensive level of care

Staffing Requirements: All crisis services staff are trained physicians, preferably psychiatrists, RNs, LPHAs, QMHP-CSs, or Paraprofessionals (Behavioral Health Technicians)

Enhanced Crisis Services

Screening and Assessment Timeframes: Face to Face triage or screening by QMHP-CS

within 15 minutes of presentation LPHA or RN completes crisis assessment

within 1 hour of referral from the screening process

Location: Crisis Outpatient Services are office-based

outpatient services Community Mental Health Centers (CMHCs)

may provide extended hours or time on weekends to deliver walk-in crisis services


Continuity of Care: Upon resolution of the crisis, every eligible

individual shall be transitioned into Service Packages 1-4 if determined to be medically necessary, or receives Crisis Follow-Up (SP5) throughout a 30-day period until he/she is stabilized and/or transitioned to appropriate behavioral health services.


Extended Observation Services: Emergency and crisis stabilization services

are provided to individuals in a secure and protected, clinically staffed (including medical and nursing professionals), psychiatrically supervised treatment environment with immediate access to urgent or emergent medical evaluation and treatment. Individuals who cannot be stabilized within 48 hours would be linked to the appropriate level of care (inpatient hospital unit or CSU).

Extended Observation Services

Staffing Requirements: Physicians, (preferably psychiatrists) RNs (APNs),

LPHAs, QMHPs (PAs), and Paraprofessionals (Behavioral Health Technicians)

Screening and Assessment Timeframes: Triage by RN or Physician within 15 minutes of

presentation Individuals who are not referred for care

elsewhere after triage receive a full assessment (psychosocial, psychiatric and as ordered medical) initiated within one hour of the individual’s presentation to the extended observation services


Screening and Assessment Timeframes, cont.: Staffing patterns should allow individual reassessment at least every 15 minutes for behavioral health technicians, two hours for nursing, four hours for QMHPs, and 12 hours for physicians, preferably psychiatrists


Continued care Staffing: A physician preferably a psychiatrist on call

24 hours/day to evaluate individuals face to face or via telemedicine as needed;

At least one LPHA on site 24 hours/day, seven days/week;

At least one RN on site 24 hours/day, seven days/week; and

Behavioral health technician(s) on site 24 hours/day, seven days/week


Location: Secure location with immediate access to

urgent or emergent medical evaluation and treatment

If services are provided for children and adolescents, the physical plant must have separate child, adolescent, and adult observation areas.


Coordination of Care: Consists of identifying and linking the

individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service. This includes contacting and coordinating with the individual’s existing services providers in a timely manner and in conformance with

applicable confidentiality requirements.


Short-term residential treatment designed to reduce acute symptoms of mental illness provided in a secure and protected clinically staffed, psychiatrically supervised, treatment environment that complies with a crisis stabilization unit licensed under Chapter 577 of the Texas Health and Safety Code and Title 25, Part 1, Chapter 411, Subchapter M of the Texas Administrative Code.

Crisis Stabilization Units (CSU)

Child and Adult: Provide short-term, community-based

residential, crisis treatment to persons with some risk of harm who may have fairly severe functional impairment. These facilities provide a safe environment with clinical staff on site at all times however they are not designed to prevent elopement and individuals must have at least a minimal level of engagement to be served in this environment. The recommended length of stay is from 1-14 days.

Crisis Residential

Staffing Patterns: There is an on-call roster of clinical

(QMHP-CS and above) and nursing (RN and LVN) staff. There is a process for assessing and anticipating staffing needs to ensure clinical or nursing staff are on-site at all times. Behavioral health technicians and nursing staff may used on the overnight shift.

Crisis Residential

Screening and Assessment Timeframes:

Prior to admission to the Crisis Residential Unit individuals receive a full psychiatric assessment within 24 hours of the individual’s presentation to the service if not referred directly from an active inpatient unit or psychiatric emergency service.

Crisis Residential

Screening and Assessment Timeframes, cont.:

Individuals, not currently in services or for whom the health status is unknown, receive a comprehensive nursing assessment by an RN within 1 hour of presentation

If ordered, individuals receive a physical health assessment by an RN, within two hours of entering a crisis residential unit unless already conducted within the last week. This evaluation includes assessment of medical and psychiatric stability, self- administration of medication capability, vital signs, pain, and danger to self or others.

Crisis Residential

Treatment Interventions:

An array of treatment interventions may exist in the crisis residential setting and may include individual or group psychotherapy or psychoeducation, crisis intervention and crisis psychotherapy, family therapy, advocacy, help with obtaining community supports and housing, help developing social skills and a social support network, substance abuse treatment, and relapse prevention. A minimum of 4 hours per day of such programming should be provided. Individuals who have significant substance abuse comorbidity receive counseling designed to motivate the patient to continue with substance abuse treatment following discharge from the program.

Crisis Residential

Location: Crisis residential services units provide a

safe environment; however they are not designed to prevent elopement. They are to provide as normalized of an environment as possible, with 16 beds or

less. All medications are securely stored.

Crisis Residential

Coordination of Care: Coordination of emergency services is

provided for every individual. Coordination of emergency services consists of identifying and linking the individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service.

Crisis Residential

Child and Adult: Provide short-term, community-based

residential, crisis treatment Individuals in a crisis respite have no risk of

harm to self or others and may have some functional impairment and require direct supervision and care but do not require hospitalization

Generally serves individuals with housing challenges or assist caretakers who need short-term housing for the persons for whom they care to avoid a mental health crisis.

Utilization of these services is managed by the LMHA based on medical necessity.

The recommended length of stay is 1-7 days.

Crisis Respite

Child and Adult: Staffing Patterns: There is a defined process for

on-site staff to obtain supervision, consultation, and evaluation when needed and for medical and psychiatric emergencies 24 hours a day from a physician, preferably a psychiatrist, APN, or PA. Mental health aide(s)/behavioral health

technician(s) are on site 24 hours a day, with numbers, qualifications, and training sufficient to ensure patient and staff safety and the provision of needed services.

Staff members providing in-home crisis respite services to children or adolescents are Qualified Mental Health Professionals competent to provide crisis services to children and adolescents.

Crisis Respite

Child and Adult: Screening and Assessment Timeframes: Prior to

admission to Crisis Respite Services, individuals receive a full crisis assessment by a physician, preferably a psychiatrist, LPHA, RN or other Qualified Mental Health Professional.

Treatment Interventions: Individual and group skills training are provided at the crisis respite site and are based on the needs of the individual and the goals of their individual crisis plans. A stable therapeutic environment exists in

facility-based crisis respite units that includes assigned personnel and scheduled activities.

Crisis Respite

Child and Adult: Location: Contracted assisted living

facilities used for crisis respite units are subject to licensing regulations of the Department of Aging and Disability Services (DADS) as Assisted Living Facilities. These services can occur in houses,

apartments, or other community living situations

Crisis Respite

Child and Adult: Coordination of Care: Coordination of

emergency services is provided for every individual. Coordination of emergency services consists of identifying and linking the individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service.

Crisis Respite

Available as part of Community Investment Incentive Funding

Provide immediate access to assessment and a continuum of stabilizing treatment for individuals presenting with behavioral crises.

These units are co-located with licensed hospitals or Crisis Stabilization Units (CSUs) and have the ability to manage the most severely ill individuals at all times, including immediate access to emergency medical care.

PESCs must be available to individuals who walk in, and contain a combination of service types including Extended Observation and Inpatient Hospital Services or a CSU.

Psychiatric Emergency Service Centers (PESCs)

Staffing Patterns: A physician, preferably a psychiatrist on call 24 hours/day to evaluate individuals face to face or via telemedicine as needed; At least one LPHA on site 24 hours/day, seven

days/week; At least one RN on site 24 hours/day, seven

days/week; and Behavioral health technician(s) on site 24

hours/day, seven days/week.


Screening and Assessment Timeframes: Individuals who are not referred for care elsewhere after triage receive a full assessment that is initiated within one hour of the individual’s presentation. Individuals who receive an assessment see a

psychiatrist within eight hours of presentation to the PESC.

The unit has sufficient staff to allow for individual reassessment at least every 15 minutes for behavioral health technicians, two hours for nursing, four hours for QMHPs, and 12 for physicians, preferably psychiatrists.


Treatment Interventions: Treatment planning places emphasis on crisis intervention services necessary to stabilize and restore the individual to a level of functioning that does not require hospitalization. An LPHA is responsible for providing the

individual with active treatment including psychoeducation, crisis counseling, substance abuse counseling, and developing a plan for returning to the community that addresses potential obstacles to a successful return.


Location: Services are co-located with a DSHS licensed hospital or CSU. The LMHA must have a written agreement

with the hospital or CSU with which the PESC is co-located.

Facilities are accessible and meet all Texas Accessibility Standards.

Facilities have provisions for ensuring safety.


Location, cont.: Offices have at least one designated area

where persons in extreme crisis can be safely maintained until transported to another level of care (e.g., hospital or crisis stabilization unit).

Facility spaces afford privacy for protection of confidentiality.

If services are provided for children and adolescents, the facility must have separate child, adolescent, and adult treatment and observation areas.


Coordination of Care: Coordination of care consists of identifying and linking the individual with all available services necessary to stabilize the crisis and ensure transition to routine care, providing necessary assistance in accessing those services, and conducting follow-up to determine the individual’s status and need for further service. This includes contacting and coordinating with the individual’s existing services providers in a timely manner and in conformance with applicable confidentiality requirements.


Local Crisis Service PlansPresenters: Chris Dickinson and

Dorcas WashburnCommunity MHSA Program Services Section

Local Crisis Planning

LMHAs shall develop, update and maintain a Crisis Service Plan designed to meet the needs and priorities of the community and to meet the following objectives

Rapid response Local stabilization when possible Diversion from incarceration Reduced burden on law enforcement Decreased utilization of emergency

healthcare resources


Community stakeholders are a vital part of the local planning process and will be key in successful implementation of crisis services.

Local Crisis PlanningCommunity Stakeholders Involved: Client representatives Client family member

representatives Child and adult

advocates Mental health service

providers Emergency healthcare

providers Local public

healthcare providers Law enforcement

Probation and parole department staff

Judicial representatives from each county

Outreach, Screening, Assessment and Referral (OSAR) provider(s)

Substance abuse service providers

Others deemed appropriate by the LMHA (such as concerned citizens, private sector)

The Crisis Service Plan shall include a description of the collaborative process and efforts (include ongoing efforts to engage stakeholders who are not involved)


Crisis Service Plans shall include a description of the current service gaps or community needs related to the delivery of crisis services for adults, adolescents and children, as well as gaps related to the delivery of crisis services to individuals with co-occurring psychiatric and substance use disorders.


Crisis Service Plans shall include a description of how the new crisis funding will be used to improve first Contractor’s Hotline and Mobile Crisis Outreach Team infrastructure, training, and crisis response processes to achieve American Association of Suicidology accreditation and meet DSHS promulgated standards


The Crisis Service Plan shall include a description of existing crisis response system to include:

Type and quantity of crisis services provided

Flowchart describing crisis response system Staff make-up Training requirements Budget

How funds will be applied to meet Hotline and MCOT standards


How remaining new crisis funding will be used for enhancement or to implement the following services and bring into compliance with new standards:

Crisis Outpatient Services (Children or Adult) Extended Observation Crisis Stabilization Unit Crisis Residential (Children or Adult) Crisis Respite (Children or Adult) Psychiatric Emergency Service Centers Crisis Intervention Team (CIT)/Mental Health Deputies

Program Crisis Transportation


CRISIS PLANNING

The Crisis Service Plan shall include:

A description of how the LMHA will coordinate with other local crisis response systems

How services provided will improve or develop the local crisis response system’s ability to divert individuals from incarceration, or find alternatives to psychiatric hospitalization.

Any written agreements between crisis response entities and any marketing/public relations efforts to inform the community about the changes in the crisis response system.

A description of strategies that will maximize the funding available to provide crisis services, including any collaboration with local or regional stakeholders


LBB & Contract PerformancePresenters: Chris Dickinson and

Karen RuggieroCommunity MHSA Program Services Section

Measuring Accountability

DSHS must report to the Legislative Budget Board (LBB) and the Governor on the implementation of crisis services

***************************************************

DSHS is adding Performance Measures to the Performance Contracts for all LMHAs

LBB and Contract Performance

Psychiatric hospitalizations after community-based crisis services:

The percent of persons with a front-door or community mental health crisis episode at LMHAs with a State or Community psychiatric hospitalization within 30 days after the end of the crisis episode.

Exclusions and limitations to contract performance measures will be noted within Information Item C.

Contract Performance Measures

Linkage to community-based services as appropriate:

The percent of persons with a front-door mental health crisis episode that is followed by a community mental health level of care authorization (LOC-A), and/or a service encounter at a DSHS-funded substance abuse treatment facility or at an Outreach, Screening, Assessment and Referral (OSAR) provider within 14 days of their front-door crisis episode.



Transition from the crisis assessment to crisis follow-up services:

The percent of persons with a front-door mental health crisis episode who have a follow-up community mental health LOC-A = 5, and who receive a crisis follow-up service encounter within 30 days of the crisis assessment.



Psychiatric hospitalizations with/without a crisis assessment within the community prior to admission:

The percent of persons who have a State or Community psychiatric hospitalization and have a crisis assessment within 5 days prior to their hospitalization. This measure excludes persons hospitalized who have a community mental health LOC-A = 1 through 4.



Crisis Changes to Report IIIPresenters: Natalie Cloudy

Chris Dickinson and Rod SwanCommunity MHSA Contractor Services Section

Line 759 Crisis Services

To include all new crisis funding used for crisis services

New Line – Crisis Services

B.2.3 New Crisis Services

To report new Crisis dollars only

New Strategy – Crisis Services

Crisis Residential/Inpatient Crisis Outpatient Crisis Screening and Eligibility Crisis Other

Crisis Services – Sub-strategies


The existing Adult and Child Strategies include the Crisis Sub-strategies: Crisis Residential/Inpatient Crisis Outpatient Crisis Screening and Eligibility Crisis Other



A Mapping Document is in development to map Encounter Codes, Procedure codes, and Authority Functions to Report III Sub-strategies.

New Report III Crosswalk

DSHS is implementing a number of significant changes to the mental health service array and to the mental health encounter field definition documents in FY2008. To the greatest extent possible, Client Assignment

and Registration (CARE) codes and service grid codes are being replaced with the American Medical Association’s industry standard Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.

FY08 MH Service Array Changes

The negotiated date for full transition from the use of services grid codes, to the use of procedure codes is March 1, 2008, which is the beginning of quarter 3.

For technical assistance, email LMHA encounter submission contact personnel to: [email protected]


LMHA personnel can find both the FY2008 mental health service array, and the mental health encounter field definitions the Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW). Both files are in the CA General Warehouse Information Folder under Specifications.

INFO_Mental_Health_Service_Array_Combined_FY08.xls; and

INFO_Encounter_Field_Defn_FY08.xls.


Any modifications made to the FY2008 mental health service array document should now be easily identifiable by the modification date column within the file.


In the past, any service within the mental health service array could be reported as delivered in response to a crisis, just by flagging the service as a crisis service when reporting the encounter. Is it ever appropriate to provide a financial

benefit eligibility determination service to an individual in crisis?


Crisis Services

The transition from service grid codes to procedure codes will only allow for a group of existing services to be delivered in response to a crisis. The services available for delivery in response to a crisis will ultimately be reported by procedure code, and will contain an “ET” modifier.


Crisis Services

These services are:

Psychiatric Diagnostic Interview Examination; Routine Case Management; Psychosocial Rehabilitative Services

(Rehabilitative Case Management); Pharmacological Management; Administration of an Injection; Medication Training and Supports; Individual/Family and Group Counseling; and Respite Services.


Crisis Services

Some existing services are uniquely defined as services that are provided in response to a crisis. It is not necessary to report theses services with the “ET” on the: Crisis Intervention Services;

Crisis Stabilization Unit Services; and

Crisis Residential Services.


Crisis Services

A series of new crisis services have also been added to the service array as a result of the crisis redesign initiative. The new crisis services have been added to the service category ‘Crisis Services,’ which is currently coded to service grid codes 1505 & 2505: Crisis Transportation (staff time, and funding

provided); Crisis Follow-Up and Relapse Prevention (one

staff, and second staff); Safety Monitoring; and Crisis Flexible Benefits (staff time, and funding

provided).


Crisis Services

One of the smallest changes made to the encounter field definitions as a result of the crisis redesign initiative resulted in one the largest concerns noted among LMHAs: The concern was the ability to report accurate

encounter data with the inclusion of the first billed payer code of CRD (crisis redesign).

Enhanced crisis services; and New crisis services


Crisis Services

DSHS acknowledges that the first billed payer code is a best guess at the time of service delivery, and as such the first billed payer code is generally not subject to audit during encounter data verification. DSHS may request further information


Crisis Services

DSHS expects that Report III will reflect the final distribution of the funding expended in each of the categories in the new crisis strategy B.2.3. Crisis Residential/Inpatient;

Crisis Outpatient;

Crisis Screening and Eligibility; and

Crisis Other.


Crisis Services

UM Guidelines for SP0 & 5Presenters: Molly Lopez

Vicki Belinoski and Perry Young

Community MHSA Program Services Section

Utilization Management

Utilization Management GuidelinesChildren’s Services Crisis Services: Package 0 Crisis Follow-up Services: Package 5

Purpose of Service Package

Brief interventions provided in the community setting Intended to ameliorate the crisis situation and

prevent utilization of more intensive services Desired outcome = resolution of the crisis, avoidance

of more intensive and restrictive intervention and prevention of additional crisis events.

Children’s Service Package 0


Core Crisis Services

Crisis Intervention Services

Psychiatric Diagnostic Interview Examination

Pharmacological Management

Laboratory Services Safety Monitoring

Crisis Transportation

Crisis Flexible Benefits

Crisis Respite

Extended Observation

Children’s Crisis Residential

*See UM guidelines grid for expected average utilization

Authorization for Crisis Services

These services do not require prior authorization. However, UM must authorize within 2 business day of presentation for crisis services. If further crisis follow-up and relapse prevention services are needed then the individual may be authorized for Service Package 5.

Any service offered must meet medical necessity criteria.


Admission Criteria

Diagnosis No mental health diagnosis is required.

CA-TRAG Meets criteria on CA-TRAG for Service Package

0.


Admission Criteria

Special Considerations The individual meets the definition of a crisis cited

in the Community Standards Rule: Crisis--A situation in which: (A) because of a mental health condition: (i) the individual presents an immediate danger to self or others; or (ii) the individual's mental or physical

health is at risk of serious deterioration; or


Admission Criteria

Special Considerations, cont. The individual meets the definition of a crisis cited

in the Community Standards Rule: Crisis--A situation in which: (B) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk

of serious deterioration.


Provider Qualifications

Crisis Intervention Services: QMHP-CS

Pharmacological Management: MD, RN, PA, Pharm-D, APN, LVN

Psychiatric Diagnostic Interview Examination: LPHA

Safety Monitoring: QMHP-CS or trained paraprofessional (Behavioral Health Technician)


Provider Qualifications, cont.

Extended Observation: Trained paraprofessional (Behavioral Health Technician)

Crisis Respite: Trained paraprofessional (Behavioral Health Technician)

Children’s Crisis Residential Services: QMHP-CS

Crisis Transportation: No restrictions



Oriented towards youths who have been discharged from crisis services or hospitalization

The major focus is on ameliorating the situation that gave rise to the crisis event, ensuring stability, and preventing future crisis events.


Purpose of Service Package, cont.

Includes ongoing assessment to determine crisis status and needs, provides time-limited (up to 30 days), brief, solution-focused interventions to individuals and families

Focuses on providing guidance and developing problem-solving techniques to enable the individual to adapt and cope with the situation and stressors that prompted the crisis event.



Core Services Crisis Follow-up and

Relapse Prevention Medication Training

and Support Counseling Routine Case

Management Psychiatric Diagnostic

Interview Examination


Laboratory Services

Crisis Transportation


Crisis Respite


Admission Criteria

The individual has been released from crisis services or hospitalization and either:

The individual is not eligible for Service Packages 1 – 4; or

The individual has opted to seek services from an external provider, but continued follow-up is indicated until referral access is complete.



Crisis Follow-up and Relapse Preventions: QMHP-CS Counseling: LPHA Routine Case Management: QMHP-CS Psychiatric Diagnostic Interview Examination: LPHA Pharmacological Management: MD, RN, PA. Pharm

D, APN, LVN Medication Training and Support: QMHP-CS, CSSP Crisis Respite: Trained paraprofessional


Utilization Management

Utilization Management GuidelinesAdult Services Crisis Services: Package 0 Crisis Follow-up Services: Package 5


Services in this package are brief interventions provided in the community that will ameliorate the crisis situation and prevent utilization of more intensive services.

The desired outcome is resolution of the crisis and avoidance of more intensive and restrictive interventions or relapse.

Adult Service Package 0


Core Crisis Services

Crisis Intervention Services

Psychiatric Diagnostic Interview Examination


Laboratory Services Safety Monitoring

Crisis Transportation Crisis Flexible Benefits Day Programs for

Acute Needs Extended Observation Crisis Residential

Services Crisis Stabilization

Unit*See UM guidelines grid for expected average utilization

Authorization for Crisis Services

These services do not require prior authorization. However, UM must authorize within 2 business day of presentation for crisis services. If further crisis follow-up and relapse prevention services are needed then the individual may be authorized for Service Package 5.

Any service offered must meet medical necessity criteria.


Admission Criteria

Diagnosis No mental health diagnosis is

required for admission to Crisis Services.

Adult TRAG Meets criteria on Adult TRAG for

Service Package 0.


Admission Criteria

Special Considerations The individual meets the definition of a crisis cited

in the Community Standards Rule: Crisis--A situation in which: (A) because of a mental health condition: (i) the individual presents an immediate danger to self or others; or (ii) the individual's mental or physical

health is at risk of serious deterioration; or


Admission Criteria

Special Considerations, cont. The individual meets the definition of a crisis cited

in the Community Standards Rule: Crisis--A situation in which: (B) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk

of serious deterioration.



Crisis Intervention Services: QMHP-CS

Pharmacological Management: MD, RN, PA, Pharm-D, APN, LVN

Psychiatric Diagnostic Interview Examination: LPHA

Safety Monitoring: QMHP-CS or trained paraprofessional (Behavioral Health Technician)


Provider Qualifications, cont.

Extended Observation: Trained paraprofessional (Behavioral Health Technician)

Crisis Residential Services: QMHP-CS




Maintaining the individual’s stability and preventing further crises and assisting individual’s in obtaining the services they need.

Crisis follow-up includes ongoing assessment to determine crisis status and needs, provides time-limited (up to 30 days) brief, solution-focused interventions.



Core Services Crisis Follow-up and

Relapse Prevention Routine Case

Management Psychiatric Diagnostic

Interview Examination Pharmacological

Management Crisis Transportation

Medication Training and Support

Counseling – Individual and Group

Crisis Respite – In-home

Crisis Respite – Not In-home



Admission Criteria

Diagnosis Any mental health diagnosis may be used for

Crisis Follow-up eligibility.

Adult TRAG Individuals who have been stabilized in SP-0 or

who have been released from psychiatric hospitalization, and who are not eligible for SP-1 through SP-4

or


Admission Criteria

Adult TRAG Individuals who have been served and stabilized in

SP-0 or released from psychiatric hospitalization and who are eligible for SP-1 through SP-4 for which there is no current capacity to provide the service package they need

or

Individuals who have opted to seek services from another provider, but continued follow-up is indicated until referral is completed.


Admission Criteria

Special Consideration

Medicaid recipients may not be underserved due to resource limitation.



Routine Case Management: QMHP–CS or CSSP

Psychiatric Diagnostic Interview: LPHA

Pharmacological Management: MD, RN, PA, Pharm.D, APN, LVN

Crisis Follow-up and Relapse Prevention: QMHP-CS, Licensed medical personnel, other personnel (consult with Program Rules for specific credential requirement.)



Medical: Licensed medical personnel

Counseling: LPC, LCSW, LMFT, Licensed Psychologist, or someone working on the corresponding licensure under the supervision of a licensed person.

Crisis Respite: Trained paraprofessional (Behavioral Health Technician)



Special ProjectsPresenter: Lauren Lacefield-LewisCommunity MHSA Program Services Section

DSHS has set aside approximately 30% of the funding from the Legislature for Community Investment Incentive crisis projects.

Communities must be willing to invest 25% of the cost of the project in new local resources to support the crisis services to be eligible for Psychiatric Emergency Service Center or proposals for diversion from incarceration or State hospitalization funds.

Investment Incentive Funding

26% will be used to fund Psychiatric Emergency Service Center or Projects that will divert people from incarceration prior to booking or State hospitalization

4% will be used to fund Outpatient Competency Restoration Projects

Of the 30% Community Investment Incentive Funding


Community Investment Incentive funds will be reserved for:

Establishment of Psychiatric Emergency Service Centers,

Projects focusing on diverting individuals from incarceration prior to booking or alternatives to State hospitalization, and

Outpatient Competency Restoration

programs.


Project Selection

DSHS will evaluate all competing requests for funding to ensure best value for the use of state funds across the system.


Extent of local and regional collaboration; Level of coordination with local and

regional healthcare and law enforcement; Program design, including integration with

other local and regional crisis services; Size of geographic area to be served; Size of population to be served; and Demonstrated need for 23-48 hour

observation services, including utilization of existing capacity in the region.

Psychiatric Emergency Services Center

Defined crisis service (e.g. crisis residential service, Crisis Stabilization Unit, 23-48 hour hold, crisis respite, or purchase of local hospital beds and associated services)

Minimization of officer wait time; Local collaboration and support, Coordination with judiciary system and

law enforcement; Timeliness of implementation; and Clinically appropriate program design.

Jail & State Hospital Diversion Project

Demonstrated need; Integration with existing services; Level of coordination with judiciary

system and law enforcement; and Innovation and alignment with evidence-

based practices including the integration of mental health, substance use treatment and physical health.

Outpatient Competency Restoration

FY 2008 Q1 requirements for requesting Community Investment Incentive funds provided to LMHAs and NorthSTAR

FY 2008 Q1 requirements for requesting Outpatient Competency Restoration funds provided to LMHAs and NorthSTAR

FY 2008 Q2 proposal for funding due to DSHS – Friday February 29, 2008

Timelines

FY 2008 Q3 Community Investment Incentive projects selected by DSHS

FY 2008 Q4 Sites selected notified

FY 2008 Q3 Contract Amendments executed

FY 2008 Q4 Community Investment Incentive projects begin implementation

Timelines

Thanks for joining us today.

For more information on Crisis Redesign& Competency Restoration

Consult the following web page:

http://www.dshs.state.tx.us/mhsacsr/default.shtm

Documents

Crisis Services Redesign Implementation Overview for LMHA’s Presenter: Mike Maples, Director MHSA