NETWORK180 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS HOME-BASED SERVICES

Transcription

1 NETWORK180 PROVIDER MANUAL SECTION 1: SERVICE REQUIREMENTS HOME-BASED SERVICES Provider will be in compliance with regulations and requirements as outlined in the Michigan Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services chapter, as well as the Lakeshore Regional Entity Contract Attachment A: Service Description for Home- Based Services. In addition to these, Provider must adhere to the following specific requirements. Services 1. Home-Based Services Provider must also provide Targeted Case Management services. This is necessary to allow for a smooth transition of care between Home-Based Services and Targeted Case Management, minimizing the impact of change experienced by families. 2. Provider must have the ability to submit CAFAS/PECFAS data electronically at intake assessment, every three months, and at discharge. 3. Provider will be expected to use a CQI process between supervisors and staff completing the CAFAS/PECFAS to ensure consistency and accuracy. 4. Utilize and encourage the integration of Mentor/Community Living Supports (CLS) Services into treatment, unless the child receives Wraparound services and the Wraparound agency is the identified provider of this service in the Wraparound/treatment plan. If Home-Based Services and Wraparound are being provided at different agencies, the family shall choose which agency they want to provide this service. CLS Services must be provided in accordance to the Lakeshore Regional Entity Attachment A: Service Description for Community Living Supports Services. 5. Provider must have crisis intervention availability 24 hours a day, 7 days a week. 6. Provide psychiatric evaluations within 30 day of identified need, as well as monitoring and provision of medications for children authorized for these services, unless the child receives Wraparound services and the Wraparound agency is the identified provider of this service in the Wraparound/treatment plan. a. Psychiatric coverage will remain the responsibility of the referring provider for up to 30 days post discharge, unless the child receives Wraparound services and the Wraparound agency is the identified provider of this service in the Wraparound/treatment plan. If Home-Based Services and Wraparound are being provided at different agencies, the family shall choose which agency they want to provide this service. 7. Provider must have the ability to coordinate Respite Services and successfully manage allotted budget amounts, unless the child receives Wraparound services and the Wraparound agency is the identified provider of this service in the Wraparound/treatment plan. If Home-Based Services and Wraparound are being provided at different agencies, the family shall choose which agency they want to provide this service. Respite Services must be provided in accordance to the Lakeshore Regional Entity Attachment A: Service Description for Respite Services. 8. Coordinate services with the primary health care provider using the Notification/Coordination with Primary Care Physician form. Coordination with the primary health care provider will include documentation of diagnosis and medications if applicable, and will occur ongoing as needed. 9. Complete the Child Health and Developmental Screening form. 10. Provider must coordinate other medically necessary services they are not currently contracted to provide. 11. If the child is in foster care, Provider must coordinate with the foster care agency a minimum of once monthly, document this contact using the Foster Care-Therapist Coordination Form, and keep a copy of it in the child s file. 12. Complete assessment and admission for Psychiatric Inpatient Hospitalization, Partial Hospitalization, Residential, and Crisis Residential admissions. 1 10/1/16

2 a. Provider must have face-to-face contact with the child if receiving any of the above mentioned services when the length of stay is greater than or equal to three days. b. Provider must have face-to-face contact with the child within seven days following discharge from the above mentioned services. 13. Update demographics, financials, and health measures when a significant change occurs, or minimally annually. 14. Billable Activity: a. Provider cannot bill during a monthly probation meeting. b. Provider cannot bill during a court hearing. Services provided to the child/family before/ after the court hearing are billable. c. Provider cannot bill for attendance at an IEP meeting. Provider may bill during a school meeting if the school meeting is used for behavior planning, clinical support, and sharing information to better serve the child. Provider will need to ensure the school is not billing Medicaid for that time as well. d. Provider cannot bill for attending a psychiatric assessment, medication review or medical appointments. e. Provider cannot bill time in the detention facility. f. Provider can bill when visiting a child who is receiving Psychiatric Inpatient services. The notes must reflect discharge planning and returning to the community. g. Provider may bill during crisis assessments. Provider can bill for the time they are actively providing clinical service such as stabilizing and assessing. Time spent coordinating with the hospital, coordinating transportation, and other coordinating functions is considered indirect non-billable time. 15. If the child/family is seeking placement in a residential setting, or the child is placed in a residential setting, Provider is responsible for following the guidelines set forth in the Out of Home Placement referral and requirement documents. 16. If a child is placed in Hawthorn, Provider must: a. Orchestrate the admission with the family. b. Maintain weekly contact with the Hawthorn therapist. c. Provide a weekly update to the Child and Family Ombudsperson referencing psychiatric stabilization and discharge planning. d. Maintain contact with the family and plan for discharge to the family home. Access and Authorization 1. Individuals seeking Home-Based Services through the public mental health system must access these services through the Network180 Access Center or Kent School Services Network (KSSN) screening site if a youth attends a KSSN school. 2. The Access Center or KSSN screening site will authorize an appropriate level of service based on: a. The results of an in-person clinical screening, and b. Collaboration with the child/family in accordance to person/family-centered planning principles. 3. A child/family requesting a screening for eligibility must be seen within 14 days from the request for service. 4. If a child is being enrolled in Wraparound services, a change in level of care to a Home-Based Services authorization may be recommended by the Community Team in conjunction with an approval for Wraparound. Network180 will review the change in level of care recommendation and authorize Home-Based Services if the request meets eligibility requirements. 5. The child/family will be given the opportunity to choose a provider from the available provider panel. 2 10/1/16

3 6. Initial authorization to Home-Based Services will be for four months with minute units. It is anticipated that the majority of cases (85%) will be stabilized in the initial authorized period and stepped down to the least restrictive level of care that meets the child s mental health needs. 7. KSSN screening sites will fax the KSSN Authorization Fax Cover Sheet, KSSN Behavioral Health Care Plan, and Demographic Intake and Financial Intake Forms to the Network180 Reimbursement Unit. An authorization will be faxed to Provider. 8. If requesting services for a sibling of an authorized child, the Sibling Services Brief Screening Form and Demographic Intake and Financial Intake Forms must be included with the request for services. The Network180 Utilization Management (UM) Department will review the authorization request and authorize as appropriate. Reauthorization 1. Network180 will determine reauthorization for Home-Based Services. The reauthorization determination will be based on the following criteria: a. There has been a recent significant event that may lead to a high probability of decompensation without continued Home-Based Services (e.g., death of a loved one, assault, hospitalization). b. Treatment goals have not been completed but there is a clear plan for completion within the next one to two months. c. Transitioning children that potentially meet Adult Targeted Case Management criteria if the child is turning 18 within the next 90 days (referral for adult services screening can be made). d. Family is transitioning out of Network180 services with a clear home-based transition plan. 2. The request for reauthorization must be submitted as early as 30 days in advance of the expiration date and no later than 14 days prior to the expiration date of the current authorization. Supervisors are required to sign off on this request. 3. The reauthorization request must be submitted on the In-Home Services Reauthorization Request Form and shall be accompanied by the most recent quarterly report. 4. At the time of the reauthorization request, Provider will verify and document the individual's eligibility for Network180 services by providing updated Demographic Intake and Financial Intake Forms (including Ability to Pay) to the Reimbursement Unit. All relevant documentation supporting medical necessity for the service must be included in the request. 5. If eligible, reauthorization will be given for at least one month with minute units but not more than two months with minute units. Utilization Management Review Process 1. The request for reauthorization will be reviewed by a Utilization Review (UR) Specialist. If medical necessity for the service is supported by the documentation submitted, the UR Specialist will enter the authorization as requested and fax the authorization to Provider using the electronic health record electronic faxing system. 2. If the documentation provided does not support medical necessity for the service being requested, or if documentation does not support the amount, scope or duration of the request, the UR Specialist will notify Provider of the decision on the Service Authorization Review Form, and, if applicable, authorizes the service based on the amount, scope or duration determined by the reviewer. 3. Network180 will send Notice of Action and appeal information to the individual or guardian as appropriate. Provider shall be available to the individual or guardian to discuss the rationale for the utilization decision, assist with other options as suggested, and, if requested, provide assistance with filing a local appeal and/or requesting a Medicaid Fair Hearing. 3 10/1/16

4 Discharge 1. The discharge date must be submitted to the Network180 Access Center within seven calendar days of discharge. The Access Center will enter the discharge date based on the information given by Provider. 2. Provider will submit discharge CAFAS data electronically. 3. Upon discharge, Provider will give the family the Parent Guide to Re-accessing Network180 Services. 4. Provider will send all discharge summaries to the Access Center within 30 calendar days of discharge from Home-Based Services. 5. The discharge summary shall provide discharge recommendations. If Provider is recommending less intensive services or other community service, discharge recommendations shall include the service, the service provider, and the appointment date/time. 6. These services are expected to be moderate in duration to stabilize the family situation and set up services as necessary. a. It is anticipated that cases will be discharged when clinically appropriate, including prior to the expiration of the initial authorization. b. It is anticipated 85% of cases authorized will be successfully discharged from services by the expiration of the initial authorization. Multi-Systemic Therapy (MST) Multi-Systemic Therapy (MST) is a family and community-based treatment for youth with complex clinical, social, and educational problems (e.g., violence, drug abuse, school expulsion). Over a period of three to six months, MST is delivered in homes, neighborhoods, schools, and communities by Master's level professionals with low caseloads. A crucial aspect of MST is its emphasis on promoting behavior change in the youth's natural environment. Initial family sessions identify the strength and weaknesses of the adolescent, the family, and their transactions with extra familial systems (e.g., peers, friends, school, parental workplace). Identified problems throughout the family are explicitly targeted for change, and the strengths of each system are used to facilitate such change. Although specific strengths and weaknesses can vary widely from family to family, several problem areas are typically identified for serious juvenile offenders and their families. Multi-Systemic Therapy is a program designed to provide intensive services to adolescents and their families between the ages of 12 and 17 as an alternative to out-of-home placement due to delinquent or anti-social behavior. Treatment is based on the adolescent s needs with a focus on the family unit. The nine principles of MST services are: 1. Principle 1: The primary purpose of the assessment is to understand the fit between the identified problems and their broader systemic context. 2. Principle 2: Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change. 3. Principle 3: Interventions should be designed to promote responsible behavior and decrease irresponsible behavior among family members. 4. Principle 4: Interventions should be present-focused and action-oriented, targeting specific and well-defined problems. 5. Principle 5: Interventions should target sequences of behavior within and between multiple systems that maintain identified problems. 6. Principle 6: Interventions should be developmentally appropriate and fit the developmental needs of the adolescent. 7. Principle 7: Interventions should be designed to require daily or weekly effort by family members. 8. Principle 8: Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes. 4 10/1/16

5 9. Principle 9: Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members needs across multiple systemic contexts. In addition to the Home-Based Services requirements above, Providers of this service must adhere to the following specific requirements. Services 1. Provider must be or become a Michigan Department of Health and Human Services (MDHHS) certified Home-Based program. 2. The average length of stay in the program is five months. 3. The expected caseload is four to six families per FTE therapist. 4. Families must be seen no less than two hours of in-person contact time per week and two hours of indirect contact per week. Contact hours include time spent with the adolescent, as well as with family members. 5. Follow-up evaluations must be conducted at 6, 12, and 18 months after termination of services. 6. Provider must regularly schedule weekly team meetings involving all MST staff. 7. Provider must monitor the adherence of program staff to the MST model using required fidelity tools provided by the MST Institute. 8. Provider is responsible for assessing the needs of the entire family and referring for other mental health services or community resources. Credentials 1. Master s level staff are required to supervise treatment teams. 2. All staff providing this service will possess a master s degree in social work, psychology, child development or a related field. These staff will have experience providing individual, group, marital or family counseling services. They should have at least three years post-degree experience working with delinquent adolescents and their families in community-based settings. 3. All MST therapists shall be assigned to the MST program on a full-time basis. 4. Professional staff must possess certification or licensure appropriate to the services they provide in accordance with the Medicaid Provider Manual. 5. Professional staff must complete a comprehensive orientation by Provider prior to providing services to children. 6. Specifically related to MST, professional staff must comply with the following: a. MST program staff shall be trained by the MST Institute in Charleston, South Carolina. The Orientation Training consists of a 5-day intensive training. The objectives of the initial five-day training shall be: i. To familiarize participants with the scope, correlates, and causes of the serious behavior problems addressed with MST family preservation; ii. To describe the theoretical and empirical underpinnings of MST using family preservation; iii. To describe the family, peer, school, and individual intervention strategies used in MST; iv. To train participants to conceptualize cases and interventions in terms of the principles of MST; and v. To provide participants with practice in delivering multi-systemic interventions. b. It is expected that participants will have read pre-assigned sections of the MST treatment manual prior to the initial training. c. The Program Supervisor will be expected to attend an additional two-day supervisor training in Charleston, South Carolina. d. One and one-half day booster sessions shall occur on a quarterly basis. 5 10/1/16

6 e. Therapists and their supervisor shall participate in weekly telephone consultation with their designated MST consultant. Access and Authorization 1. Kent County Circuit Court Family Division probation officers and Department of Health and Human Services staff will make all referrals to the MST program. 2. The MST Clinical Supervisor determines eligibility based on: a. The results of an in-person clinical screening, and b. Collaboration with the adolescent/guardian in accordance to person/family-centered planning principles. 3. The MST Clinical Supervisor will fax the request for authorization, along with the Demographic Intake and Financial Intake Forms to the Network180 Reimbursement Unit. An authorization will be faxed to Provider. 4. Initial authorization for MST services will be for five months. Reauthorization 1. Reauthorization determination will be based on the following criteria: a. High probability of decompensation without continued MST services. b. Treatment goals have not been completed but progress is anticipated. c. Continued high risk for out-of-home placement. 2. Provider determines that the family requires services beyond the initial authorization period and requests a reauthorization by faxing the updated Demographic Intake and Financial Intake Forms to the Network180 Reimbursement Unit 14 days prior to the expiration of the current authorization. 3. Reauthorization will be given for one additional month. Not more than one reauthorization request can be made for a total of six months of service, per the MST model guidelines. 4. Network180 will send Notice of Action and appeal information to the individual or guardian as appropriate. Provider shall be available to the individual or guardian to discuss the rationale for the utilization decision, assist with other options as suggested, and, if requested, provide assistance with filing a local appeal and/or requesting a Medicaid Fair Hearing. Discharge 1. The discharge date must be submitted to the Network180 Access Center within seven calendar days of discharge. The Access Center will enter the discharge date based on information given by Provider. 2. Provider shall submit discharge CAFAS data electronically. 3. Upon discharge, Provider will give the family the Parent Guide to Re-accessing Network180 Services. 4. Provider will send all discharge summaries to the Access Center within 30 calendar days of discharge from MST. 5. The discharge summary shall provide recommendations. If Provider is recommending less intensive services or other community services, discharge recommendations shall include the service, the service provider, and the appointment date/time. 6 10/1/16