CMHRS TRANSITION INTO MEDALLION 4 AND CCC PLUS

Transcription

1 CMHRS TRANSITION INTO MEDALLION 4 AND CCC PLUS

2 Strategic Transition to Managed Care Two managed care programs CCC Plus Serving older adults and disabled Includes Medicaid-Medicare eligible 216,000 individuals Long-term services and supports in the community and facility-based, acute care, pharmacy Incorporating community mental health Implementation started Aug 2017 Implement statewide by Jan 2018 Medallion 4.0 Serving infants, children, pregnant women, parents 760,000 individuals Births, vaccinations, well visits, sick visits, acute care, pharmacy Incorporating community mental health New procurement 2017 Building on two decades of managed care experience Implement statewide 2018 Approximately $30B over 5 years Estimated $10B - $15B over 5 years 2

3 DMAS Contracted Health Plans M4 and CCC Plus 3

4 6 Health Plans Statewide Aetna Better Health of Virginia Anthem HealthKeepers Plus Magellan Complete Care of Virginia Optima Health United Healthcare Virginia Premier Health Plan 4

5 CCC PLUS/MEDALLION 4.0 SERVICE AUTHORIZATION GUIDANCE The guidance that follows reflects input from each of the CCC Plus/Medallion 4.0 MCO Behavioral Health Leads. The purpose of this guidance is to increase efficiency for providers to submit the most accurate and relevant, recovery-oriented continued authorization request. 5

6 BUILDING A CONTINUED SERVICE AUTHORIZATION REQUEST Agency staff can complete and submit both initial and continued stay authorization request forms. Under the clinical direction of the agency s licensed type mental health professional, the member s direct care staff should be included in the process of completing the request. The direct care staff can begin building the continued authorization request by defining in the ISP how progress will be measured. To build the request form throughout the course of the current authorization period, providers should include measurable data and ongoing notations associated with current clinical presentation and progress towards treatment goals. Potential or recommended changes to the specific treatment interventions and/or treatment objectives listed in the ISP should include a description of how member progress will be measured as identified in the ISP. 6

7 Individual and Recovery Based Treatment 7

8 WHAT DO THESE MEMBERS HAVE IN COMMON?

9 CASE #1-FAILED SERVICE 72 year old with diagnosis of major depressive disorder, moderate and generalized anxiety disorder. Last psychiatric hospitalization was in Member resides in an ALF, does not intend to live independently, has a payee and participates in Psychosocial Rehabilitation Services 56 hours per week. Other services including case management and medication management. MHSS goals include accessing transportation, budgeting, and socialization. Member has been receiving MHSS services for 7 years with little progress toward goals.

10 CASE #2-SKILL BUILDING IN PROGRESS 24 year old with diagnosis of bipolar disorder whose last psychiatric hospitalization was 8 months ago at Central State Hospital. Member with a prior hospitalization at age 16 at the Commonwealth Center for Children. Member desires to live independently in an apartment. MHSS goals include medication adherence, budgeting, appropriate communication skills, learning to access housing and community resources, illness education, and performing daily hygiene. Member has been receiving MHSS services for 5 months. Member s other services are monthly case management and medication management.

11 CASE #3-SUPPORT V. SKILL BUILDING 56 year old with diagnosis of schizoaffective disorder who lives in a group home. MHSS goals include social skills, accessing community resources and learning to independently take medications and schedule appointments. Member has been receiving MHSS services for 3 years. Submitted clinical information states the treatment plan for social skills is for the MHSS Q to transport member to member s PSR program which member attends 5 days per week. Member has had no progress toward goals to date, remains dependent on others to schedule appointments and organize medications, and does not desire to engage in community activities.

12 CASE #4-MHSS GOALS MET 56 year old with diagnosis of schizoaffective disorder and alcohol use disorder in remission. Lives in a group home. Member has diabetes and hypertension. Member has monthly case management and psychiatric services. MHSS goals include medication adherence, appointment and AA adherence, hygiene, and keeping living space clean/organized. Member has been in MHSS for 2 years and is making ongoing progress toward MHSS goals. Member has learned to set up a pill box and to schedule appointments on his own. Regularly attends AA, has begun showering 4x per week (compared to once per week) and living space is no longer in a disheveled state. Active discharge planning is in process.

13 CASE #5-WRONG LEVEL OF SERVICE Member is 43 year old with diagnoses of major depressive disorder, cocaine use disorder, and borderline personality disorder. Member participates in twice-weekly psychotherapy with a psychologist. MHSS goals include appropriate communication, identifying and processing trauma triggers through cognitive behavioral strategies, scheduling appointments, accessing transportation. Member has been in MHSS services for 3 years. Member s difficulties with dysfunctional social interaction, stress vulnerability, and chronic intermittent crisis remains unchanged. Member has shown no independence in scheduling appointments and accessing transportation. No change in nutritional habits. Overspends budget each month. Articulates no intention to discontinue recreational cocaine use, and no linkages to ARTS services have been pursued and/or established.

14 WHAT DO THESE MEMBERS HAVE IN COMMON? Five Different Real Members Five Different Clinical Scenarios, Histories, and Co-Morbidities Different Levels of Stability and Independence Different Complexity and Intensity of Goals Different Levels of Progress v. Potential Failed Service Different Duration of Time in MHSS Services Different Array of Concomitant Supports and Other Services

15 WHAT DO THESE MEMBERS HAVE IN COMMON? The Same Authorization Request. 260 Units over 6 Months

16 RECOVERY MODEL IN MENTAL HEALTH

17 PERSONALIZED MEDICINE THE RIGHT CARE WITH THE RIGHT PROVIDER AT THE RIGHT DOSE AT THE RIGHT TIME

18 AUTHORIZATION TIPS Individualize the service, number of units, time frame requested and the expected duration of service to the individual client s needs avoid blanket, generic requests. If member receiving other services such as PSR, specify what goals will be addressed in MHSS that are different than the goals being addressed in the other service. Do not submit multiple pages that simply describe member s symptoms or social challenges. Specify what goals are being addressed by MHSS to target which functional deficits, how the goals are being addressed, and whether progress is occurring toward goals (for continued stay).

19 AUTHORIZATION TIPS Remember DMAS intent for MHSS a time-limited skill building service, not a chronic, long term support service. Ask yourself, do I expect member to make ongoing, sustained progress at this point in time? Remember the goal of MHSS is skill building, not to be a substitute for trauma-based or other psychotherapies (regulations prohibit Q s from doing psychotherapy), or crisis-management or other higher levels of care. Fill out form completely. For example, if history of intensive treatment/hospitalization is left blank or filled out without detail as to where and when, then you have not submitted the information required to meet basic eligibility criteria per DMAS guidelines. The effort upfront saves additional work on your part on the back end.

20 AUTHORIZATION TIPS Specifically address why individualized training is required why can t the member s needs be met in other less intensive or group-based outpatient and recovery-based services Include active discharge planning as part of the authorization and re-authorization process Document efforts at care coordination with member s other services (e.g., ARTS, PSR, Case Management) Do not start an initial service prior to authorization retroauthorization is a no-go

21 AUTHORIZATION TIPS Ask yourself, does the service meet the DMAS definition of a failed service.maximal benefit is it time to taper and transition to alternative services? Virginia Medicaid General CMHRS UM Guideline MNC includes a service as not medically necessary when the service meets the definition of a failed service. "Failed services" or "unsuccessful services": as measured by ongoing behavioral, mental, or physical distress, that the service or services did not treat or resolve the individual's mental health or behavioral issues (12VAC ). Discharge is required when the individual has achieved maximal benefit from this level of care and their level of functioning has not improved despite the length of time in treatment and interventions attempted. Community Mental Health Rehabilitative Services provider manual chapter IV.

22 AUTHORIZATION TIPS If no progress is occurring document what will be done differently.how will the treatment plan change? If sustained progress has occurred and goals are being achieved,, update and taper units commensurate to the residual level of skill building needs If member resides in an ALF and does not intend to live independently, assess whether proposed goals are already being addressed by ALF services (e.g., medication management for a member who already receives medications from ALF staff and is adherent to taking medications) For members in LTSS support services, specify how MHSS goals differ from needs and/or goals addressed through LTSS Home Health/Personal Care Services Submit initial authorization forms for initial requests and continued stay forms for continued stay requests

23 Member and Service Information/Medical Necessity Attestation and Medication Status 23

24 Member and Service Information/Medical Necessity Attestation and Medication Status 24 - Please ensure that all the demographic information is filled out accurately and completely (Member name, organization, clinical contact with direct phone number, etc) - Service requested with appropriate modifiers along with from and to date span of service, units requested, and total #hours of service per week. - Please put in the accurate initial admission date to service (This is the first date that this service was delivered to this member) - Medications- Please note that having a recent prescription(s) for psychotropic medication(s) is a requirement for H0046. However, it is important to have the current medications listed for all service authorizations to ensure appropriate coordination of services and collaboration with the providers, the MCOs and other service providers. - Ensure that the accurate ICD-10 Diagnosis is included

25 Member and Service Information/Medical Necessity Attestation and Medication Status Individualizing the Treatment: The individualized treatment goals should be reflected in the treatment request (Units requested should not be standardized units, they should match the member s needs). Ensure the request is individualized and appropriate to the member s needs and reflecting or matching the members most current treatment plan. For example if the members goal is to access transportation and manage hygiene the request should match the hourly needs to accomplish those training or treatment goals. 25

26 Member and Service Information/Medical Necessity Attestation and Medication Status 26 Initial admission date of service: What was the first date the service was delivered? The initial admission date may not be the same as the first MCO claim i.e) services started in 2014 under the BHSA. If there was a lapse in service greater than 30 days, indicate the date the member resumed service delivery as the admission date. Average number of units per week: Describe Average number of units planned per week in the field provided Average number of units per day: Describe the Average number of units planned per day in the Extra Notes section at the end of the request form. Primary ICD-10 Diagnosis: The most current/recent diagnosis related to the primary Mental Health need for the service. Medications: Indicate the current dosage Example: Sertraline, 50mg, once per day

27 Member and Service Information/Medical Necessity Attestation and Medication Status CMHRS Attestation The Dated Signature of LMHP Type verifies that: 1) a timely SSPI and applicable re-assessments were done in accordance with current CMHRS SSPI requirements; and 2) the individual continues to need the service and meets the eligibility criteria for the service Behavioral Therapy Attestation The Dated Signature of LBA or LMHP Type verifies that: 1) a timely assessment and applicable re-assessments were done in accordance with current Behavioral Therapy requirements; and 2) the individual continues to need the service and meets the eligibility criteria for the service 27

28 Care Coordination 28

29 Care Coordination Provider Initial Brief Screening & Health Risk Assessment Patient Available Services Community Partners 29

30 Care Coordination - Defined Care Coordination Collaborative Sharing Information Goals are to: Improve healthcare Improve health and wellness of those with complex and special needs Integrate Services around needs Ensure members receive appropriate services and desirable treatment outcomes Service descriptions, authorizations request, and documentation shall include descriptions of any coordination with internal agency providers and also with any providers not employed by your company. Care Coordination is a required activity Lack of Care Coordination may impact authorization status 30

31 Care Manager Defined Care Managers Engage in care coordination to support the service authorization process as opposed to Care Coordinators who provide direct work in the community Can be included on any treatment team meetings or discussions Can be consulted with regarding referring a member to another service or provider Collaborates with participating providers to support authorization requests. 31

32 Care Coordination-Described Include current services provided on your authorization request. i.e. Name of Service, Provider Contact, Frequency Explain how care coordination is working to achieve member recovery and treatment goals? Providers from different programs are expected to coordinate their services and plans to ensure a comprehensive and integrated approach Describe how other services, not provided by your company, compliment and align with recovery and treatment goals and avoid unnecessary duplication of this service s treatment interventions. 32

33 Care Coordination-Described Include and evaluate: What does the member s day/week look like with the other services they receive? How does the frequency of this service fit into the member s schedule of other treatment services Include Collaboration Frequency: Example: coordination and frequency of collaboration between the MHSS and PSR provider or between the IIH and TDT provider, psychiatrist and other medical providers. Best practice would be to collaborate whenever treatment goals are revised and updated to ensure coordinated care delivery. 33

34 Treatment and Member Strengths, Resources and Barriers 34

35 Treatment and Member Strengths, Resources and Barriers Definitions: Person-centered: A collaborative process where the individual participates in the development of his treatment goals and makes decisions about the services provided. Example: I want to return to work 1 day a week. Recovery oriented services: Providing support and assistance to an individual with mental health and/or substance use disorders so that the individual (i) improves his health, recovery, resiliency, and wellness; (ii) lives a self-directed life; and (iii) strives to reach his full potential. 35

36 Treatment and Member Strengths, Resources and Barriers Definitions Continued: Trauma informed: A strengths-based framework that is responsive to the impact of trauma, emphasizing physical, psychological, and emotional safety for both service providers and survivors; and creates opportunities for survivors to rebuild a sense of control and empowerment. Rehabilitative Services: According to CMS, includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level. The expectation of the service is that it is more than support. The service should result in progress towards the individual s person centered goal. 36

37 Treatment and Member Strengths, Resources and Barriers Guidance: Describe the strengths and resources that would impact recovery for the individual (how will these influence treatment goals and recovery goals-how are they using these skills to overcome barriers or influence treatment? (EX: Tom has a strong work ethic and history of gainful employment. Tom will begin volunteering and will work towards his goal of returning to work 1 day a week.) Describe Examples of Current Barriers: that impact the members ability to engage or participate in the service, treatment or recovery goals: (EX: Tom continues to experience paranoid thoughts that prevent him from working with others on the job.) Will the individual be able to benefit from the service? (EX: Mental Health Skill Building will assist Tom in Developing effective coping skills which will allow him to maintain reality testing while on the job.) 37

38 Treatment and Member Strengths, Resources and Barriers Guidance Continued: Describe how baseline psychiatric symptoms, intellectual functioning, cooccurring (SUD, ID) conditions, physical health conditions, support systems, financial issues, housing, and/or family involvement are barriers and how they are being addressed (treatment goals and care coordination activities must address these barriers). How have the strengths or resources improved since the last authorization request? (Example: Tom has identified 2 volunteer Opportunities.) Is it time to taper and transition to alternative services? Include or update discharge planning goals (Example: Tom has been working 1 day a week and will soon start working 2 days a week. He is able to step down to outpatient therapy weekly.) If no progress is occurring document what will be done differently.how will the treatment plan change? (Example: Tom will begin participating in group therapy 1x a week.) 38

39 Treatment and Member Strengths, Resources and Barriers When a Continued Stay Request May not be Approved: Virginia Medicaid General CMHRS UM Guideline MNC includes a service as not medically necessary when the service meets the definition of a failed service. "Failed services" or "unsuccessful services": as measured by ongoing behavioral, mental, or physical distress, that the service or services did not treat or resolve the individual's mental health or behavioral issues (12VAC ). Discharge is required when the individual has achieved maximal benefit from this level of care and their level of functioning has not improved despite the length of time in treatment and interventions attempted. Community Mental Health Rehabilitative Services provider manual chapter IV. 39

40 Treatment Planning and Measurement 40

41 Treatment Planning and Measurement Guidance: Developing Member Centered ISP Goals Goal and Objectives must be recovery focused, relevant to the member, and achievable. Use the ISP as a guide which should include the member s general goals as translated into specific, measureable goals and objectives Goals should be taken directly from the treatment plan that already incorporated the member s voice and choice as developed with the member. Taking into account the person s base line functioning and symptoms, what is realistic recovery going to look like at discharge? What is the expected improvement in each ISP goal area? 41

42 Treatment Planning and Measurement Guidance: Developing Member Centered ISP Goals Describe the prioritization used in the development of the treatment goal as it relates to the individual s barriers to treatment and severity of symptoms. Apply timelines whenever possible. The timeline may change as the member engages. However, it is important to always collaborate with the member on timeline goals. If timelines are appropriate, set markers of success. Those markers may be self-budgeting, going to appointments independently, or completing a calendar for the week. The best plan of care would include both markers of success and timelines to monitor progress. 42

43 Treatment Planning and Measurement Guidance: Developing Goal Focused Service Interventions Each service the provider provides should be accounted for in the plan of care and have a goal. Treatment goals should target the person s specific functional impairments/deficits and all service interventions/activities should align with these treatment goals. Describe symptom management and recovery strategies for each of the current goals to measure functioning or self-regulation or management of the condition. Describe the staff assigned to implement each goal whether a LMHP type or QMHP. Take into consideration other services the member may be receiving from other providers. How do those services impact treatment and how do those service goals align with your plan of care? Be aware of soft services that may enable a member and be something that is not trackable. These considerations should be incorporated in the treatment plan. 43

44 Treatment Planning and Measurement Guidance: Describing Progress in each treatment goal (how is progress being measured?) Describe progress measurement, describe recovery-based progress. What is the current expected progress for the goal or objective? Include timelines for achieving goals or break down goals into smaller measurable outcomes to promote success. Identify the person s baseline functioning. The goals of all treatment is to produce substantial and enduring changes in the individual s behaviors, cognitions and moods and more useful strategies for managing their dayto-day lives. Compare the progress to the baseline to indicate the current strategy. Progress, for example should not be measured by indicating a total elimination of the symptoms. While it is not expected that each individual will achieve a total elimination of symptoms, there should be targeted restoration of baseline functioning, preventative skills to reduce relapse, and progress in recovery goals that improve day-today functioning and readiness for further care in the least restrictive environment. 44

45 Treatment Planning and Measurement Guidance: Describing Progress in each treatment goal (how is progress being measured?) If there is a lack of progress what changed for the individual that impacted their delivery. What is being done to address the lack of progress with new or revised treatment goals and objectives? Are there unmet needs or other resources that would help support the member.? Do timelines need to be adjusted? What barriers need to be overcome? What does the member identify as barriers? Can goals be broken down into smaller increments to target skills and learning? Are there member strengths that can be leveraged? 45

46 Treatment Planning and Measurement What tools were used to measure progress? Ex: ADHD screening tools, depression screening tools, how do you track psychosis, medication adherence? If sustained progress has occurred and goals are being achieved, update and taper units commensurate to the residual level of skill building needs. MHSS Specific Guidance: If member resides in an ALF and does not intend to live independently, assess whether proposed goals are already being addressed by ALF services (e.g., medication management for a member who already receives medications from ALF staff and is adherent to taking medications) For members in LTSS support services, specify how MHSS goals differ from needs and/or goals addressed through LTSS Home Health/Personal Care Services 46

47 Treatment Progress-Family Involvement and Service Specific Requirements 47

48 Treatment Progress-Family Involvement and Service Specific Requirements For IIH, TDT, and EPSDT- Family involvement is a required activity for the provision of these services as well as being a vital component of effective treatment. Please keep in mind that authorization approval is contingent upon the identification of an parent or guardian who will maintain weekly involvement with the service provider. This includes participating in weekly family counseling, participating in treatment teams, ISP construction, and supporting coordination of services. It is important to document in the continued stay if there are ongoing issues related to the parental involvement whereby the parent/guardian becomes a barrier to effective treatment. For MHSS members under the age of 21 years of age- Please note that if a member is not currently living in an independent living situation, the expectation is that the member should be actively engaged in transitioning to a more independent living situation within the next 6 months. It is important to describe in detail the progress that has been made towards this transition. 48

49 Treatment Progress-Family Involvement and Service Specific Requirements Describe progress measured regarding specific family involvement goals and objectives including a description of the methods used to measure progress within each goal area; Describe progress toward achieving educational goals with other care providers (EG: Medicaid Waiver funded Attendants, Relatives, etc.) who routinely come in contact with the member; Describe the generalization of adaptive functioning in multiple settings and describe the progress toward the anticipated date of discharge from services including all fading and consultative actions as planned; and Describe the ongoing need to have a clinician involved with the member and family or authorized representative to provide treatment services and define why services cannot be provided at a lower level of care. 49

50 Discharge Planning 50

51 Discharge Planning Estimating Discharge Date Should be appropriate to the service Not 2 years out Based on current status/progress/treatment goals When do I anticipate the remediation of this member s significant functional impairments to such a degree that they could be safely managed with lower level treatment interventions and/or other community services? Describe how you will determine remediation and appropriateness of lower level treatment and other community services? Do Not leave Blank Including Specific Step Down Care Type of Service Agency/Professional name & Contact Information Any intake or upcoming appointments If no appointments schedules, address alternatives 51

52 Discharge Planning Should include caregivers/ support system Examples: Family Therapy NAMI caregiver support groups Should include specialized step down care Examples: Trauma Therapy Support Groups Social Groups After School Activities Should include resources Example: Food Bank Programs / Food Closets Housing resources Educational/ Vocational Programs Disability/ Waiver Information Financial Resources 52

53 Discharge Planning Barriers to Discharge: If step down services or step down providers have not been identified, please identify the barrier to discharge planning and steps taken to address these barriers. Discharge begins at admission An estimated date of discharge should be included Identifying GAPS in care early and assisting members in locating and engaging services Should include behavioral health and medical Collaboration with CMs or other providers should be part of the discharge process. Should be comprehensive in nature and involve more than out patient counseling supporting either the maintenance of new skills or a transition to an appropriate level of care 53

54 Discharge Planning Take Credit for your work Document all efforts to assist your clients in being successful 54

55 Thank You 55