OUTPATIENT SERVICES providers of this service and all contracted services will be held accountable to the General performance specifications

Transcription

1 OUTPATIENT SERVICES Providers contracted for this level of care or service will be expected to comply with all requirements of these service-specific performance specifications. Additionally, providers of this service and all contracted services will be held accountable to the General performance specifications, located at the beginning of this section of the Provider Manual. The General Performance Specifications contained herein pertain to the following outpatient services: Outpatient Mental Health and Substance Abuse Services Facility-Based, Group Practice, Individual Practitioners Outpatient Services Home-Based and Non-Facility Based Outpatient Services School-Based Intensive Outpatient Mental Health or Substance Abuse services Acupuncture and Ambulatory Detoxification services Psychological Testing Dialectical Behavior Therapy Assessment for Safe and Appropriate Placement (ASAP) Please refer to these performance specification attachments for these specialty services. Outpatient Services are those behavioral health services that are rendered in an ambulatory care setting, such as an office, clinic environment, a Member s home, or other locations appropriate to the provision of service for psychotherapy or counseling. Services focus on the restoration, enhancement, and/or maintenance of a Member s level of functioning and the alleviation of symptoms that significantly interfere with functioning in at least one area of the Member s life (e.g., familial, social, occupational, educational). Active family/guardian/ natural supports involvement is important unless contraindicated. The goals, frequency, and length of treatment will vary according to the needs of the Member and the response to treatment. A clear treatment focus, measurable outcomes, and a discharge plan (including the identification of realistic discharge criteria) will be developed as part of the initial assessment and treatment-planning process and will be evaluated and revised as necessary. Outpatient services that emphasize time-effective episodes of care will likely be sufficient for most Members seeking outpatient treatment, including those with more serious and persistent behavioral health conditions. Some Members, however, may require specialty outpatient services, pharmacotherapy, and /or ongoing, intermittent contact with a licensed mental health professional (e.g., once or twice per month) to maintain the individual s optimal level of functioning, to ameliorate significant and debilitating symptoms, and to prevent the need for more intensive levels of care. 128

2 All Outpatient Services performance specifications also apply to Medication Management. Components of Service 1. Outpatient Service providers will provide the following: Diagnostic evaluation Individual, couples, group, and family therapies, including short-term, solution-focused outpatient therapy Case and family consultation 2. Outpatient Service providers will provide the following, or ensure referral for same: Psychopharmacological services (including medication, evaluation, and ongoing medication monitoring and management) Psychological testing 3. Outpatient Service providers provide emergency services 24 hours per day, seven days per week to all Members enrolled in the outpatient program/clinic/practice. These services are intended to be the first level of crisis intervention whenever needed by the Member. a. During operating hours, these services are provided by phone and face-to-face through emergency appointments as warranted by the Member s clinical presentation. b. After hours, the program provides an emergency phone number that accesses a clinician either directly or via an answering service. c. Any call that is identified as an emergency by the caller is immediately triaged to a clinician. d. A clinician must respond to emergency calls within 15 minutes. This clinician provides a brief assessment and intervention minimally by phone. e. Based upon these emergency services conducted by the provider both during operating hours and after hours, the provider may refer the Member, if needed, to an Emergency Services Program (ESP) for an emergency behavioral health evaluation. f. An answering machine or answering service directing callers to call 911 or the ESP, or to go to a hospital emergency department (ED), is not sufficient. 4. Providers ensure that each Member receives a program orientation 129

3 describing the process of care at the initiation of services. 5. The provider will have policies and procedures, including intake and discharge criteria, and provide staff training specific to the particular service being rendered (e.g., home-based, school-based, etc.). 6. Outpatient providers will build and maintain the capacity to serve Members with special needs. They will adhere to their own internal, written protocols for treating special populations (e.g., children, elders, developmentally disabled, cultural and linguistic minorities, homeless, co-occurring disorders, etc.) and/or offering appropriate referrals. 7. Providers build and maintain a treatment model designed to serve Members with serious and persistent mental illness. The model includes approaches and information that support and facilitate Members recovery from serious and persistent mental illness and linkage with appropriate DMH personnel. 8. In treating mental health disorders, providers educate Members and, with informed consent and as clinically indicated, their families/guardians/significant others about the use and risks of medication, recovery, and symptom management. Staffing Requirements 1. For children and adolescents, the clinician is the one who works primarily with children and adolescents, or who can demonstrate competence through the provider s credentialing program to work with children and adolescents. Any clinician who works with children and adolescents who does not meet the above criteria must receive routine supervision from an independently licensed clinician who can demonstrate competence through the provider s credentialing program to work with children and adolescents. 2. Psychopharmacological services for children and adolescents up to age 14 are provided by a psychiatrist who is board certified in child/adolescent psychiatry. 3. The provider will ensure that all clinical work is supported by regularly scheduled and ongoing clinical supervision and consultation as appropriate. Senior clinical staff must be available for consultation (including a psychiatrist as needed) during all hours of operation regarding emergency situations. 130

4 Service, Community, and Collateral Linkages 1. In an effort to improve continuity of care, outpatient providers will have strong working relationships with ESPs, Inpatient, ICBAT/CBAT, and providers of other diversionary or 24-hour levels-of-care. They will have this documented through written affiliation agreements, minutes of regularly scheduled meetings, and/or evidence of collaboration in Members medical records. Process Specifications Access Assessment and Treatment Planning 1. Members who are not in crisis and do not require immediate services, but present with an urgent request for services, will be scheduled for an outpatient therapy appointment within 48 hours, and they will be given the after-hours telephone number with appropriate emergency instructions. 2. Members with routine requests for services are offered an outpatienttherapy appointment occurring within 10 business days of request. 3. Members referred from an inpatient unit will be scheduled for an outpatient therapy appointment within seven days from the date of discharge from the inpatient unit. 4. Members referred from an inpatient unit will be scheduled for a psychopharmacological appointment as soon as clinically indicated, but no longer than 14 business days post-discharge. 5. Outpatient providers are expected to be proactive in facilitating Member attendance at initial and ongoing appointments, such as via outreach and follow-up, reminder phone calls or mailed notices, assistance with transportation arrangements, etc. 6. If the Member does not keep an appointment, the clinician will attempt to contact the Member or parent/guardian within 24 hours and document the attempt, including unsuccessful attempts, in the Member s medical record. 7. Outpatient providers offer operating hours that are responsive to the needs of Members and their families, including a range of appointment days and hours, offering evening and weekend appointments as possible and appropriate. 1. When a Member in outpatient treatment is evaluated by an ESP and/or admitted to Inpatient, ICBAT, CBAT, or any 24-hour level of care and/or when Members are being referred to the outpatient provider from the inpatient/icbat/cbat unit the outpatient provider will: a. receive and return phone calls from ESPs and providers of 131

5 inpatient or other 24-hour levels-of-care who are servicing the clinician s outpatient client within one business day; b. provide information and consultation, with appropriate consent, in order to inform the assessment of the Member by the ESP and/or 24-hour level-of-care; c. make every effort to participate, face-to-face or by phone, in the facility treatment and discharge-planning process; d. provide Bridge appointments for Members on inpatient units whenever possible; e. facilitate the aftercare plan by ensuring access to an outpatient appointment that meet the access standards above; and f. support the Member in implementing his or her aftercare. 2. The facility/provider will assign a multidisciplinary treatment team to each Member within 24 hours of admission to the outpatient program. 3. The facility/provider shall ensure that assessments are completed and that the treatment team has met to review the assessment and initial treatment plan before the fourth outpatient visit. 4. The facility/provider shall ensure that treatment plans are updated quarterly (every ninety days). 5. Facility-based providers should follow DPH regulations pertaining to Multi Disciplinary Team (MDT) review (105 CMR B and C) and case review (105 CMR : Case Review). Initial and quarterly treatment plans shall be signed by the treating clinician and an additional licensed clinician. The latter may include one of the following: Psychiatrist (MD, DO) Psychologist (PhD, PsyD, EdD) Licensed Independent Clinical Social Worker (LICSW) Licensed Certified Social Worker (LCSW) Psychiatric Nurse (RN) Advance Practice Registered Nurse (APRN) Licensed Mental Health Counselor (LMHC) Certified Addiction Counselor (CAC) Certified Alcohol and Drug Counselor (CADC) 132

6 Licensed Marriage and Family Therapist (LMFT) 6. Group Practices and Individually Contracted Practitioners will conduct a quarterly review and update of all treatment plans of Members currently in treatment. The review and update will be documented in the Member s medical record, including rationale for continued treatment based on MBHP s medical-necessity guidelines. 7. Group Practices will document evidence of multidisciplinary consultation and coordination of care within the practice, including but not limited to, such contact between treating clinicians and prescribers. 8. Individual Practitioners will document evidence of clinical consultation as needed in treating specific Members, including but not limited to, consultation and coordination or care with prescribers, including those with whom the practitioner maintains an affiliation agreement. 9. Any significant changes in the treatment plan, such as service frequency or treatment modality, will be a planned and inclusive process with the Member. Rationale for such modification will be documented in the Member s medical record. 10. Providers work cooperatively with MBHP staff in the treatment or care planning process. In particular, if there are significant difficulties implementing the treatment or care plan, the provider notifies MBHP s outpatient department or regional office as soon as significant difficulties are identified, such as the need for assistance in accessing other covered services for a Member. Discharge Planning and Documentation 1. The provider will have a written policy and procedure for the management of no-shows and cancellations. The policy and procedure will include criteria for Member notification, outreach, and discharge. 2. When appropriate and necessary, the provider initiates a thoughtful process, which includes the Member to the greatest extent possible, aimed at facilitating transfer to another source of care before terminating with the Member (e.g., community support, self-help, etc.). When a provider or Member determines that a transfer to another provider or clinician is appropriate, the decision process is mutually inclusive of all involved parties and takes into consideration issues surrounding staff safety and Member choice. Discharge of a DMH continuing-care consumer must be reviewed with DMH prior to termination of services, whenever possible. 3. For Members who are minors (except those who are emancipated), the provider presents written and verbal treatment findings and 133

7 recommendations to parents or guardians prior to transfer or termination. Additional Discharge Planning Requirements for Homeless Members 1. The provider will complete and forward to DMH a DMH eligibility packet for homeless Members who appear to meet eligibility criteria and have not already been determined for DMH Continuing-Care Services. 2. The provider will identify community resources for the homeless and ensure that all such resources are utilized to assist with discharge planning for homeless Members. 134