Monterey County Behavioral Health Clinical Documentation Guide. 01/19/2017 Revision 1

Transcription

1 Monterey County Behavioral Health Clinical Documentation Guide 01/19/2017 Revision 1

2 2 Chapter 1 INTRODUCTION... 5 Why do we have this manual?... 5 Informed decision making... 5 Confidentiality... 6 Revoking an Authorization to Use, Exchange, and /or disclose information... 7 Care Coordinator... 7 Utilization Review... 8 Chapter 2 INFORMED CONSENT Informed Consent Minor Consent Chapter 3 SERVICE DELIVERY Admission/Opening an Episode Original Date of Coordination Care Coordination Timeliness of admission Care Coordination annual renewal of services Care Coordination Transfer of services UMDAP Chapter 4 ASSESSMENT AND DIAGNOSIS The Flow of Client Information Assessment CANS and ANSA Clinical Summary Special Considerations Diagnosis/ ICD10 Code Set Included Diagnosis Excluded Diagnosis Medical Necessity Criteria Notice of Action Assessment Frequently Asked Questions about the Notice of Action Policy Chapter 5 DISCHARGE PLANNING Chapter 6 CLIENT-CENTERED CARE & TREATMENT PLANNING Family Driven Care Strengths Treatment Plan Details on Stages of Change Components of the treatment plan My Life Goals/Aspirations (in client s own words) My challenges/barriers (problem) My Hopes/Goals My Action Step (objectives) Supports (interventions) Components of a good treatment plan Chapter 7 PROGRESS NOTES Frequency of Documentation of Services Timeliness of Documentation of Services Append progress notes All About FIRP... 50

3 3 Confidentiality in progress note content Mental Health Service Codes Intensive Care Coordination (ICC) (201, 222, 208) Intensive Home Based Services (IHBS) (221, 222, 228) CRISIS INTERVENTION (271 & 272) Case Management (301) Collateral (311) Non-Billable Services (330) No Medical Necessity Codes (NO MN) Assessment (331) Triage (336) Access to Treatment teams only Individual Therapy ( 341) Mental Health Group Rehabilitation (351) Mental Health Group Therapy (353) Family Group Counseling (356) Family Therapy (357) Collateral Group Counseling (358) Crisis Team only-- Crisis Intervention (371) Mental Health Rehabilitation (381) Plan Development (391) Lockout Codes: Case Management (405), Collateral (475) & Mental Health (485) Mental Health Service Codes for medical team Medication Support Services (361) Medication Support Services-- Telepsychiatry (361-T) Medication Support Services for Urgent appointment (361-U) Medication Support Services Lock Out Setting (364) Assessment/Reassessment/Treatment Planning Linking Services To the Treatment Plan Chart of Allowable billing Chart of Billing Daily Maximum Per Client Service Code Comparison Finalizing a Note Clinical Supervision and Billing Indirect Service Codes Chapter 8 SCOPE OF PRACTICE/COMPETENCE Behavioral Health professional licenses and classifications Who can bill what codes? Who is allowed to perform what clinical activities? Controlled Substances Utilization Review System (CURES) Chapter 9 EVIDENCE-BASED PRACTICE (EBP) Wellness Recovery action plan (WRAP) Promising Emerging practices (PEP) Chapter 10 FULL-SERVICE PARTNERSHIP (FSP) Chapter 11 SPECIAL POPULATIONS Katie A. Subclass Therapeutic Behavioral Services (TBS) Day Treatment Services Chapter 12 PRODUCTIVITY Chapter 13 EXAMPLES... 88

4 4 Examples of Strengths Example of Narrative Summary and Treatment Plan based on Stages of Change Example Interventions based on the stages of Change Examples of some Intervention words Examples of Interventions for specific psychiatric symptoms Anxiety Borderline Personality Substance Use/Abuse Trauma Dependency Depression Family Conflict Bipolar Disorder Medical Issues Examples of progress notes Example Collateral Service Example Individual Rehabilitation Example Case Management Service Example Case Management Service- example Example Mental Health Service Family Therapy Example Group Rehabilitation Example Group IHBS Service EXAMPLE GROUP ICC SERVICE Chapter 14 Language Services Language Line Indigenous Interpretation Services Interpreter Services Chapter 15 Appendix Sending secure/encrypted Approved Abbreviations List Productivity Report Breakdown Evidence based/promising practice training codes Quality Improvement Disallowance codes Chapter 16 GLOSSARY Chapter 17 Audit/Changes to this guide

5 5 Chapter 1 INTRODUCTION WHY DO WE HAVE THIS MANUAL? Monterey County Behavioral Health (MCBH) is a county mental health organization (also referred to as a Mental Health Plan) that provides services to the community and then seeks reimbursement from state and federal funding sources. There are many rules associated with billing the state and federal government, thus the need for this documentation guide. In general, good ethical standards meet nearly all of the requirements. At times, there is a need to provide some guidance and clarity so staff can efficiently and effectively document for the services they provide. Although some clients receive services that are funded through grants, as a policy we do not reduce or alter documentation standards based of the client s funding source. Monterey County Behavioral Health has adopted a Compliance Program based on guidance and standards established by the Office of Inspector General, U.S. Department of Health and Human Services. The intent of the compliance plan is to prevent fraud and abuse at all levels. The compliance plan particularly supports the integrity of all health data submissions, as evidenced by accuracy, reliability, validity, and timeliness. The plan applies to staff, volunteers, trainees, and contractors working in county owned or operated sites. As part of this plan we must work to ensure that all services submitted for reimbursement are based on accurate, complete, and timely documentation. It is the responsibility of every provider to submit a complete and accurate record of the services they provide and to document services in compliance with all applicable laws and regulations. This guide reflects the current requirements for direct services reimbursed by Medi-Cal Specialty Mental Health Services, California Code of Regulations (CCR, Title 9, Division 1) and serves as the basis for all documentation and claiming in Monterey County Behavioral Health, regardless of payer source. All staff, whether directly operated by the County or Contracted Community Providers are expected to abide by the information found in this guide. Monterey County Behavioral Health implemented the use of its Electronic Medical Record (EMR) AVATAR in The intention of this manual is to provide documentation standards; a separate EMR User Guide with step-by-step instruction and videos on the use of AVATAR is available. Quality Improvement may issue updates and/or clarifications to information found in this manual via QI Connect Newsletters, Policy Clarification Memos, MCBH QI website ( and/or other acceptable modes of communication. The updates and/or clarifications are considered to be official MCBH requirements and will be incorporated into this guide as appropriate. INFORMED DECISION MAKING We strive to provide excellent quality care to every individual who receives services from Monterey County Behavioral Health (MCBH). We aim to involve the individual and/or the family in treatment in order to provide services that are meaningful to them and help them thrive. We must include the individual/family in the treatment process at the onset of services. It is our responsibility to ensure that every individual and/or family is treated with respect and that every person is informed about what services are offered from MCBH as well as provide information on treatment options in the community in a way that helps support the client in making an informed decision about whether the services offered through MCBH are right for them or for their child. All MCBH staff are expected to discuss issues related to individual s treatment along with the risks and benefits associated with these treatments in order to support the individual/family in

6 6 making an informed decision about their treatment. Equally as important is to have ongoing communication with every individual/family about the treatment process and discharge planning. In Monterey County s behavioral health system, all medical records are maintained through the use of an Electronic Medical Record (EMR), AVATAR. The EMR holds all information pertinent to the client s treatment. The medical record includes information about mental health and substance abuse services provided through MCBH programs and some community contracted providers who use AVATAR. All staff must inform, educate, and obtain consent regarding the sharing of client information, prior to any disclosure of information. CONFIDENTIALITY The confidentiality of medical, psychiatric, and substance abuse information is protected by State and Federal statutes, rules and regulations. The statues, rules, and regulations require that we protect the client s personal health information (PHI) and that we obtain informed consent from the client in order to disclose any PHI information, prior to doing so, except under specific conditions as indicated by the laws. Only staff members who are directly involved in the client s treatment may access the health record for treatment purposes. It is never okay for staff members to access a client s health record to satisfy a curiosity for their own purpose, even when the client is related to the staff member. The electronic medical record stores information on who has accessed the medical record as part of the audit trail. The audit record is necessary to make efforts to safeguard the client s confidentiality as well as to provide an account of disclosure if requested by the client or legal entities via subpoena. We recognize that there may be times when you access a client s health record in error. As an example, you may have incorrectly entered the client s medical record number and opened a client s chart before realizing your error. When a client record is accessed in error, it is important to complete the Accidental/Incorrect Client Access form in AVATAR. This form will record the error in accessing the client s health record should a reason ever need to be given to the client or legal entities. All information and records obtained in the course of providing services shall be confidential. 40 A client or authorized representative who consents to release of any and/or specific information about their health record must read and sign the Authorization to Use, Exchange, and/or Disclosure of Confidential Behavioral Health Information previously referred to as Release of Information. The Authorization, once signed, may be valid for a designated period of time or on an event. The client, or authorized representative must state who the information may be released to, the purpose for which the information may be used, what specific information may be released, and when the authorization will expire. A client may decide to revoke the Authorization, at any time and may do so by submitting the request verbally or in writing to any staff member. The Authorization will at that time be revoked, making it invalid. If the client, at a later time, decides to reactivate the Authorization, a new Authorization must be completed as indicated above. Note: Any subpoenas or requests for medical records should be directed to the Quality Improvement office. 40 Mental Health Division Policy No. 303-Medical Record Confidentiality

7 7 REVOKING AN AUTHORIZATION TO USE, EXCHANGE, AND /OR DISCLOSE INFORMATION A client may withdraw consent or REVOKE a previously signed Authorization at any time during their course of treatment (CCR, Title 9, Section 854). In the event the client asks to revoke a release of information, the behavioral health staff must complete the revoke section of the release of information form, being careful to enter a reason for revoke and notifying necessary team members of this request. For Authorizations completed on paper, you must print the Authorization, write revoke across the page and scan back into the EMR in the appropriate section. Special Considerations for minors: For minors who are eleven (11) years or younger, the authorized representative may authorize the release of information. For minors who are treated as "adults" under the law for purposes of medical consent (emancipated and self-sufficient minors) and minors seeking sensitive services for which they are qualified to provide their own consent under the law, the minor must authorize the release of information even to their own parents or guardians. The client is in control of their health information. A client has a right to view the information in their medical record, but must complete the designated request of information document (a verbal release of records will NOT be accepted). Records request may be done by visiting the Monterey County Behavioral Health Quality Improvement office located at 1611 Bunker Hill Way, Suite 120, Salinas, CA (831) A designated staff member of the Quality Improvement team will review the request to ensure a proper and timely response to client s request. Note: When information is disclosed, it is necessary to complete the Account of Disclosure form in the EMR in order to keep track of the disclosure of information. CARE COORDINATOR Monterey County Behavioral Health uses a Care Coordination (Coordinator) model for its delivery of services to the individual/family in an effort to support the individual/family s recovery. The Coordinator plays an integral part of the treatment team in supporting the client/family s access to medically necessary services and avoids duplication of services by working in conjunction with other staff and Providers to support client/family s recovery. It is important to point out that it is not the Coordinator s sole responsible for the direct delivery of all mental health services to the client; instead the Coordinator is responsible for coordinating care among service providers to meet the mental health needs of the client/family. Further, the Coordinator is responsible to ongoing assessment of the client s mental health needs and medical necessity. As noted above, there may be a variety of service providers involved in the delivery of services. For this reason we have included a Supporting Staff form in AVATAR which is used to communicate which staff is supporting the client s recovery. Once a Supporting Staff member has been added, the designated client will display on the my clients widget for the given Supporting Staff member. This option, in no way, waives client s confidentiality. Thus, we must all continue to adhere to all policies regarding confidentiality of client information. As the Care Coordinator you are responsible for maintaining communication and collaboration with treatment providers as well as maintain the accuracy and integrity of the medical record by adhering to documentation standards and timelines. The Coordinator role also includes reviewing and approving medically necessary services to be included on the client s treatment plan as well as denying those services that are deemed not medically necessary. When services are denied or modifications to the services are made, the Coordinator is responsible for communication of these needs with other staff and/or service providers.

8 8 Please note: The Coordinator is responsible for removing supporting staff members from the supporting staff list once the supporting staff member is no longer part of the client s treatment team. Reminder: The Coordinator may review the list of client s on their caseloads using the 201 Caseload report. Supporting Staff may use the 218 Other Support Staff report for a list of client s on their caseload. UTILIZATION REVIEW State regulations and Behavioral Health policies specify that beneficiary health records, regardless of format (electronic or print) go through the utilization review (UR) process. The UR process is meant to ensure the following: all planned clinical services are appropriate to address the client s mental health needs; comply with all State, Federal and Behavioral Health regulations; and maintain the integrity of the client s health records in accordance with documentation standards. We have established a Utilization Review process with an aim to review 10% of all Monterey County Behavioral Health records per calendar year. The Quality Improvement (QI) team oversees the UR processes. The UR process includes licensed staff members from the QI Team (QI Reviewers) and Supervisors (Reviewer). The roles of these reviewers are critical as they provide clinical oversight and function as a check and balance system. All Reviewers are responsible to ensure the following is met: All services meet medical necessity standards; planned services benefit the client by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning; all documents are completed within established Monterey County Behavioral Health standards; and review that treatment planning is co-authored with individual/family and written in a manner that is easily understood by the individual/family. Supervisors/Reviewers utilize the Step 3.5 Clinical Supervisory tool, while QI Reviewers use the step 3 UR tool to conduct reviews. The most significant difference between the two review tools is that although the UR tool and Clinical Supervisory tool are used to review medical necessity and quality of care, the Clinical Supervisory tool allows for the direct supervisor to provide real-time feedback to the supervisee. We recognize the importance in providing information about review findings to staff. Below are some common methods for providing feedback: 1) The Supervisor reviewing the chart may provide direct feedback to the staff member as an opportunity for further coaching and support. 2) The Quality Improvement Team complete a Quality Improvement Action Request--QIAR (MCBH Policy 493) which provides detailed information on identified issues including action steps to address the concerns. The QIAR is usually ed to the individual staff member and their immediate Supervisor. 3) The Quality Improvement team provides Service Managers and Supervisors direct feedback regarding any identified program trends. 4) Information from utilization reviews is used to review overall program or system trends when considering performance improvement projects. The QI team takes information from UR findings into consideration when exploring training needs of County and community Provider staff members. Note: The Clinical Supervisory tool---enter hyperlink and Utilization Review tool are available on our QI website (

9 9 Chapter 2 INFORMED CONSENT 2.1 INFORMED CONSENT Clients should be given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. The system should be able to accommodate differences in client preferences and encourage shared decision making. 1 Adults, including those receiving mental health services, have the right to give or refuse consent to medical, diagnostic or treatment procedures. California Health and Safety Code (a) states that "the legislature finds that adult persons have the fundamental right to control the decisions relating to the rendering of their own medical care..." California Code of Regulations, Title (b)(6) provides that a patient has a right to "participate actively in decisions regarding medical care. To the extent permitted by law, this includes the right to refuse treatment." The range of services provided shall be discussed prior to admission with the prospective client or an authorized representative so that the program's services are clearly understood. 2 Behavioral Health has an obligation to inform clients of the risks and benefits of treatment. At the onset of services, we must ensure that clients understand the content of not only the Informed Consent form but of all the onset of services documentation prior to the client agreeing to services and signing these forms. This includes ensuring that minors who are able to consent for their own services without a parent are fully educated about the similarities and differences in the types of services they can receive. In addition, although we do not need to have clients re-sign Informed Consent forms when they transfer from program-toprogram, it is important we inform them of the specific risks and benefits of each particular services when they initially transfer. An important part of informed concept is the person s capacity to consent. A person is deemed to have legal capacity to consent to treatment if he/she has the ability to understand the nature and consequences of the proposed health care, including its significant benefits, risks and alternatives (including doing nothing), and can make and communicate a health care decision. A person's lack of mental capacity to consent to medical care may be temporary or it may be permanent, and the provider should determine capacity on a case-by-case basis whenever consent is sought. For example, a client who is clearly under the influence of drugs or alcohol may lack capacity temporarily, but could provide consent at a later time, when not so impaired. If you have any questions regarding a beneficiary s ability to consent, please consult with your supervisor and Quality Improvement. 1 Institute of Medicine Committee on Quality of Health Care in America (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press. 2 CCR, Title 9, Section 532.3

10 MINOR CONSENT Please review MCBH Policy 320 Minor Consent for detailed information. The information below is a brief summary of what is contained in Policy 320. This section provides guidance regarding consent for health care services for minors receiving services from Monterey County Behavioral Health. The terms health care and medical care include assessment, care, services or referral for treatment for general medical conditions, mental health issues, and alcohol and other drug treatment. As with adult clients consenting for their own services, parents or minors who can consent for their own services have the fundamental right to consent to, or refuse medical treatment. Generally speaking, minors need the consent of their parents to receive mental health services unless the minor has the right to consent to care under minor consent laws (see Circumstances that Allow for Minor to Consent to Their Own Services). Only one parent is necessary to provide consent unless we are aware of evidence that the other parent has objected. Adoptive parents have the same rights to consent as natural parents. In the case of divorced parents, the right to consent rests with the parent who has legal custody. If the parents have joint legal custody usually either parent can consent to the treatment unless the court has required both parents to consent. In most situations, we can presume that either parent can consent unless there is evidence to contrary. Some teams prefer to obtain consent from both parents. This is not a legal requirement but this is acceptable within MCBH as long as it does not pose a significant detriment or cause harmful delay to the treatment of the client. A parent or guardian who has the legal authority to consent to care for the minor child has the right to delegate this authority to other third parties (aged 18 and older). For example, the parent may delegate authority to consent to medical care to the school, to a coach, to a step-parent, or to a baby-sitter who is temporarily caring for the child while the parent is away or at work. A copy of the written delegation of authority should be scanned into the Electronic Medical Records. In some cases, a surrogate parent is raising a minor child. If this adult is a qualified relative (often the grandparent, or an aunt or uncle, or older sibling) who has stepped into the role of parent because the biological parents are no longer willing or able to care for the child, he or she should fill out the Caregiver's Affidavit form which is used widely throughout California. These so called Caregivers who have "unofficially" undertaken the care of the child are authorized by law to consent to most medical and mental health care and to enroll these children in school. Once they have completed the Caregiver's Affidavit form (which is then scanned into the Electronic Medical Records) they may consent to medical or mental health care for the minor child; however, if the parent(s) returns, the "caregiver's" authority is ended, and once again the parent has authority to consent to or refuse care for the child. A Caregiver s Affidavit does not have to be renewed and can remain in effect until the parent returns, or until the child turns 18. The court has the power to authorize medical and mental health treatment for abandoned minors and for minors who are dependents or wards of the court (for example, kids in foster care or juvenile hall). Furthermore, the court may order that other individuals be given the power to authorize such medical and mental health treatment as may appear necessary, if the parents are unable or unwilling to consent. In some circumstances a court order is not necessary. For example, under certain circumstances, a police officer can consent to medically necessary care for a minor who is in "temporary custody."

11 11 In situations where an adult other than the parent or guardian is providing consent, (unless it is an emergency) care must be taken to establish their legal authority to consent to care before treatment begins. Often this requires identification of the child's status as well as the ability or inclination of the natural parents to provide consent. A copy of the Court Order delegating this authority (to a Foster Parent, for example) should be scanned into the Electronic Medical Records before care is provided. For those treatments for which a minor can legally provide his or her own consent, no court order or other authorization is necessary when treating a dependent or ward. In rare situations a court may summarily grant consent to medical or mental health treatment upon verified application of a minor aged 16 or older who resides in California if consent for medical care would ordinarily be required of the parent or guardian, but the minor has no parent or guardian available to give the consent. A copy of the court order should be obtained and scanned in the minor s Electronic Medical Record before treatment is provided pursuant to the order. Consent from the parent is not required if the minor is involuntarily held for a 72 hour assessment and treatment pursuant to Welfare and Institutions 324 Code or 5150 et seq. Circumstances that Allow for Minor to Consent to Their Own Services Minors generally need a parent to consent to healthcare services because minors suffer automatic legal incapacity due to their young age. However, there are certain minors who can consent for their own services. These minors are: A. Minors who are treated as "adults" under the law for purposes of medical consent. These are: a. Emancipated minors b. Self-sufficient minors B. Minors seeking sensitive services These minors do not suffer automatic legal incapacity due to their young age but must still display legal capacity. As with adults, legal capacity to consent to services indicate an ability to understand the nature and consequences of the proposed health care, including its significant benefits, risks, and alternatives; make a health care decision; and communicate this health care decision. Emancipated Minors include: A. Minors 14 and older who have been emancipated by court order; B. Minors who are serving in the active US military forces; and C. Minors who married or who have been married Before providing services to these minors, we should obtain a copy of their emancipation card or court order, a copy of their military ID card, or a copy of their wedding certificate and scan these documents into their Electronic Medical Records. Self-sufficient minors are defined by law as minors aged 15 and older who are living separate and apart from their parents and who are also managing their own financial affairs regardless of their source of income. Even though selfsufficient minors can consent to outpatient mental health services such as therapy, rehabilitative counseling, and case management, the law is not clear whether or not self-sufficient minors can consent to psychotropic medication treatment. Please consult with your supervisor and Quality Improvement if psychotropic medication treatment is part of the services being sought by a self-sufficient minor. Minors seeking certain sensitive services may be legally authorized to provide their own consent to those services. The minor also controls whether or not the parent will have access to records generated as a result of receiving those services. When minor consent applies, sensitive services should not be provided over the minor's objection. In other words, even if the parent provides consent, non-consent by the qualified minor presents ethical issues and provision of care should be delayed until consultation using the chain of command can be obtained on a caseby-case basis.

12 12 Minors 12 or older may consent to medical care and counseling related to the diagnosis and treatment of a drug or alcohol related problem. Since the law deems such minors to be legally competent to consent to such care, parents or guardians have no legal authority to demand drug testing of their minor children who are 12 or older. The law requires providers to involve the patient or legal guardian in the care, unless to do so would be inappropriate. The decision and reasons to involve, or not involve, the parent/legal guardian needs to be recorded in the Electronic Medical Records, as well as staff efforts to involve them. There are two separate California laws that permit minors 12 and older to consent to outpatient mental health counseling services. The first is Family Code 6924(b). It states that minors 12 and older may consent to mental health treatment or counseling on an outpatient basis (and also, to residential shelter services), if both of the following requirements are satisfied: 1) The minor, in the opinion of the attending professional person, is mature enough to participate intelligently in the outpatient services or residential shelter services, and 2) The minor would either present a danger of serious physical or mental harm to self or to others without the mental health treatment or counseling or residential shelter services, or is the alleged victim of incest or child abuse. The second, more recent law is found at Health and Safety Code section It removes the requirement that the provider must first determine that the minor 12 and older be at risk before services can be provided. Instead, the provider need only determine that the minor, in the opinion of the attending professional person, is mature enough to participate intelligently in the outpatient mental health services. The attending professional person should clearly chart that any required qualifying criteria have been met if services are provided pursuant to either of these provisions of the law. When outpatient mental health care or residential shelter services are provided, the laws state that it shall include the involvement of the minor's parent or guardian unless, in the opinion of the professional person who is treating or counseling the minor, the involvement would be inappropriate. The professional person must state in the Electronic Medical Record whether and when the person attempted to contact the minor's parent or guardian, and whether the attempt to contact was successful or unsuccessful, or the reason why, in the professional person's opinion, it would be inappropriate to contact the minor's parent or guardian. (Note: If outpatient mental health services are provided pursuant to Health and Safety Code , the law states that the decision to involve, or not involve, the parents shall be made in collaboration with the minor patient.). It needs to be reiterated that even though a minor 12 or over can provide their own consent for sensitive services related to substance abuse and mental health, mental capacity to provide consent and informed consent is still required. If a minor who otherwise qualifies for minor consent lacks mental capacity, and insists that there not be parental involvement, staff should consult with their supervisor and Quality Improvement so that appropriate steps may be taken. Note: Psychotropic medication treatment is not one of the sensitive services that a minor can consent for. Parent/guardian consent is required if psychotropic medications are prescribed. Parent/guardian consent is also needed if voluntary inpatient mental health facility services are provided. Further, the minor consent laws do not authorize a minor to consent to convulsive therapy or psychosurgery.

13 13 Chapter 3 SERVICE DELIVERY ADMISSION/OPENING AN EPISODE Monterey County Behavioral Health (MCBH) receives referrals from a variety of resources. Referrals for services may be by self-referral, mental health unit, Community Providers, from other counties, or the larger community. MCBH services are voluntary. All individuals who seek behavioral health services from MCBH are entitled to receive, at minimum, an assessment to determine their need and whether MCBH services might meet those needs or whether a referral is warranted to better serve the individual/family. In order for MCBH to begin the process for determination of the needs of the individual who is requesting services, we must first begin with establishing an electronic health record. The intention with establishing an health record for the individual is that it will create a unique record of the individual s request for services, the outcome of the request, as well as provide information on MCBH s responsiveness to the request for services. The initiation of a health record does not, in any way, guarantee the person will receive all or some of their mental health services from MCBH. It means the individual/family has requested mental health services and we are responding to the request. Effective January 1, 2017 the use the Call Log function in Avatar may be used to document a request for services (via telephone or in person) by someone who does not already have an open MCBH health record. The use of call log is permissible for use by Access to Treatment programs, ED Crisis Team, and to document services provided by the Officer of the Day from various programs for individuals who do not already have an open health record in Avatar. Access to Treatment teams shall use call log to document ALL initial request for service. The Crisis Team member shall use call log function to document a telephone call or in-person interaction for an individual who is not currently opened to MCBH services. For programs using Officer or SW of the Day functions, call log/preadmission may be use to document a services rendered to individuals who are not opened to MCBH services. In the event the individual already has an open health record with MCBH, all services shall be documented with the open episode. Please note, the use of the call log function requires the opening pre-admission episode in order to document the service provided. ED Crisis Team and Officer/SW of the Day must close out the pre-admission episode once documentation has been completed. Access to Treatment programs will need to close out the pre-admission episode once the individual has been seen for evaluation and is opened to a program episode or when the program makes a decision to close the preadmission. Quality Improvement team recommends a pre-admission program shall not remain open for longer than 30- days from initial request. All other programs are expected to open a client episode within the program in order to document the services provided. During the assessment period, a program may claim for mental health services in accordance with medical necessity standards and within MCBH policies. In order to begin documentation and claiming for service provided to an individual, the practitioner must first OPEN an episode prior to providing services. A program episode is considered opened in AVATAR when the following forms have been completed: Admission Admission Part 2 (Bundle): o Client and Services Information (CSI) o Admission Diagnosis AND ICD10 code set (this must be entered before any billing is submitted) o Client Relationships o Client Case Coordinator o Onset of Services

14 14 All MCBH staff are expected to discuss important issues related to treatment options along with risks and benefits in order to support the individual/family in making an informed decision about their treatment. At onset of services, the practitioner is expected to discuss and/or provide the following documents to the individual/family: TO EVERYONE Informed Consent Notice of Privacy Practices Consumer Rights MCBH Problem Resolution Authorization for use, exchange, and/or disclosure of confidential behavioral health information within Monterey County Behavioral Health Authorization to bill private insurance or Medicare Offer a copy of Guide to Medi-Cal Mental Health Services ONLY WHEN APPLICABLE Minor Consent Authorization to use, exchange, and/or disclosure of confidential behavioral health information (as indicated) Authorization to use, exchange, and/or disclosure of confidential behavioral health information for Multi-Disciplinary teams (when applicable) Unlicensed Clinician (when applicable) During the period of assessment for determination of the individual s mental health needs and the development of a course of treatment, specific service codes are permissible for documenting services rendered. ORIGINAL DATE OF COORDINATION The date in which the client is first opened to an outpatient coordinated care episode is considered the original date of coordination. This date is important because it informs the Care Coordinator about the treatment cycle, annual reassessment period, and helps MCBH comply with State and Federal regulations for the delivery of services. The original date of coordination also referred to as anniversary month, can be found in the green-colored widget in the chart overview section of the individual s medical record. Please note, on rare occasions, there may be times when the original date of coordination seems inaccurate, questions arise about this date, or there may be a clinically relevant reason for special considerations for modification of this date. In those instances, the Coordinator may submit the Error Reporting form indicating the error or reason for the change request along with supporting evidence for the request. The request will be reviewed by a QI clinical staff member and a decision will be made regarding the request. The QI team may contact the Coordinator for further information prior to making a decision. Note: Some clients may have had other services prior to this admission that are not considered coordinated outpatient episodes: TAR, ZADP, Crisis Team, NMC, FFS, MHSA-Clinic Integration, CHS, Door to Hope (when there is a county coordinator involved) DRS, Interim etc.

15 15 CARE COORDINATION TIMELINESS OF ADMISSION The Coordinator is responsible for ensuring timeliness of service delivery. Meaning, the Coordinator is responsible for making sure that all forms are completed within the designated timelines. The following forms need to be completed at the start of an initial assessment/intake or for episodes where the client was previously closed for services for 365 days or longer: Onset of Services o Informed Consent o Notice of Privacy Practices o Consumer Rights o MCBH Problem Resolution o Authorization for use, exchange, and/or disclosure of confidential behavioral health information within Monterey County Behavioral Health o Authorization to bill private insurance or Medicare o Offer a copy of Guide to Medi-Cal Mental Health Services o Minor Consent, if applicable o Authorization to use, exchange, and/or disclosure of confidential behavioral health information (as indicated) Psychosocial Assessment Mental Status MC Diagnosis (DSM-5 AND ICD-10 code set) Child Assessment of Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) MORS (if applicable) Monterey County Treatment Plan (finalized) Treatment Plan Participation Consent Special Considerations (if applicable) Client Case Coordinator form Client Relationships UMDAP - Uniform Method of Determining the Ability to Pay Unlicensed Clinician form (at the start of services provided by an unlicensed, but licensed eligible clinician) (MCBH Policy 144) The health record must meet timeliness standards in order to comply with claiming (billing) regulations and avoid disallowances. The client record must meet the above compliance requirements for billing. In the event that the client record is out of compliance, claiming for services is not allowed. In order to comply with claiming (billing), the health record must include an admission diagnosis prior to claiming any service. The diagnosis (DSM 5 criteria and ICD 10 code set) is informed by assessment. Additionally, the health record must also include 1) Psychosocial Assessment (finalized) and 2) Treatment Plan (finalized), prior to claiming for services. For claiming purposes, the service may be claimed when a diagnosis, assessment, and treatment plan have been completed and finalized. In the event the chart is out of compliance, claiming for services will not be allowed and services will automatically be moved to a non-billable service code and the progress note will continue to remain as part of the health record. In order to meet documentation expectation standards, all applicable documents listed above must be completed (as applicable). Please note: During the period of assessment for determination of the individual s mental health needs and the development of a course of treatment, specific service codes are permissible for documenting services rendered.

16 16 CARE COORDINATION ANNUAL RENEWAL OF SERVICES On an annual basis, the Coordinator is responsible for the annual evaluation of the individual s needs, which include the evaluation for medical necessity, renewal of services, maintaining the accuracy of the health record, and ensure all necessary documents are completed in a timely manner. Of note is that many of the documents previously completed at onset of services do not need to be collected again during the annual review/renewal of services, with the exception of the Authorization for Use, Exchanges, and/or Disclosure of Confidential Behavioral Health Information that have expired and Medication Consents (medical staff only). It is, however, good practice to review the limits of confidentiality and risks and benefits with the individual as often as clinically relevant. The Coordinator is responsible for the completion of the following forms, which may be completed up to 30 days prior to the anniversary month: Update Client Data Annual Plan Bundle: o Client Relationships o Mental Status MC o Psychosocial Assessment o Child Assessment of Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) o MORS (if applicable) o Diagnosis DSM 5 AND ICD10 code set (make sure to select update option) o Monterey County Treatment Plan o Treatment Plan Participation Consent (must be completed every time information on the treatment plan is added or updated o Authorization to use, exchange, and/or disclosure of confidential behavioral health information (as indicated-if expired) o Special Considerations (if applicable) o Unlicensed Clinician form (at the start of services provided by an unlicensed, but licensed eligible clinician) (MCBH Policy 144) UMDAP * MD Bundle (medical staff only, if applicable) * Note: Information gathered for completion of UMDAP should be collected for present timeframe moving forward. Meaning, there is no need to complete UMDAP information for years in which the individual was closed to prior episodes.

17 17 CARE COORDINATION TRANSFER OF SERVICES Transfer of services means that the responsibility of providing services to an individual/family has been transferred to a different MCBH program. If the services are transferred from one MCBH program to another MCBH program (with no break or closure of services in the process of transfer), most onset of services documentation do not need to be completed again, with the exception of the Authorization for Use, Exchanges, and/or Disclosure of Confidential Behavioral Health Information that have expired and Medication Consents (medical staff only). As always, it is good practice to review the limits of confidentiality and risks and benefits with the individual for the services they will receive as often as clinically relevant. The receiving MCBH program takes on the Care Coordination responsibilities and should do the following as soon as possible: Discuss risks and benefits of their particular program services with the individual/family and ensure that the individual/family clearly understand these risks and benefits before beginning services The individual s informed consent should then be documented clearly in a progress note in their health record Admission form Admission Part 2 (Bundle) form which includes the Client and Services Information (CSI) Diagnosis DSM 5 AND ICD10 code set (must be completed before claiming any service) Client Case Coordinator form Psychosocial Assessment, if applicable-update if there is significant clinical data not included in the latest version of the assessment Mental Status Exam, if applicable Treatment Plan (must update with current provider and treatment goals; non-current treatment goals must be closed by prior program or you) Treatment Plan Participation Consent Unlicensed Clinician form (at the start of services provided by an unlicensed, but licensed eligible clinician) (MCBH Policy 144) The health record must meet timeliness standards in order to comply with claiming (billing) regulations and avoid disallowances. The client record must meet the above compliance requirements for billing. In the event that the client record is out of compliance, claiming for services is not allowed. In order to comply with claiming (billing), the health record must include an admission diagnosis prior to claiming any service. The diagnosis (DSM 5 criteria and ICD 10 code set) is informed by assessment. Additionally, the health record must also include 1) Psychosocial Assessment (finalized) and 2) Treatment Plan (finalized), prior to claiming for services. For claiming purposes, the service may be claimed when a diagnosis, assessment, and treatment plan have been completed and finalized. In the event the chart is out of compliance, claiming for services will not be allowed and services will automatically be moved to a non-billable service code and the progress note will continue to remain as part of the health record. In order to meet documentation expectation standards, all applicable documents listed above must be completed (as applicable). During the period of assessment for determination of the individual s mental health needs and the development of a course of treatment, specific service codes are permissible for documenting services rendered.

18 18 Note: Please extend a level of professionalism when transferring services to another program by ensuring the integrity of the client record is up to date. In the event the client s annual plan renewal is due at the time of the transfer, the receiving program should complete all annual renewal of services documents. UMDAP Monterey County Behavioral Health (MCBH) uses the Uniform Method of Determining the Ability to Pay (UMDAP) as a sliding scale of liabilities based on clients and/or financially responsible parties ability to pay for the cost of mental health services provided. The UMDAP establishes a process for collecting client s financial information, billing clients for their financial liability, and/or collecting payment for services. This information is used to assess client/family s and/or the financially responsible party s annual liability. The client/financial responsible party are responsible for payment of actual cost of care, inclusive of all other resources such as Medi-Cal and third party payers, up to their annual liability. The UMDAP information is obtained during the intake progress and is renewed, at least, on an annual basis by completing the Family Registration forms in the Electronic Medical Record (EMR). MCBH will not withhold services from anyone based on their past due balance or inability to pay. Note: Please refer to the EMR User Guide for instructions on completing the UMDAP form.

19 19 Chapter 4 ASSESSMENT AND DIAGNOSIS THE FLOW OF CLIENT INFORMATION As each client begins services with behavioral health there is a flow of information designed to support staff in providing services that help the clients meet their recovery goals. 1. Assessment 5. Services Medical Necessity 2. Clinical Formulation 4. Treatment Plan 3. Diagnosis 1. The Assessment is the first step toward establishing medical necessity and the onset of services. 2. The assessment supports the development of the Clinical Formulation, which informs the diagnostic process and drives treatment. 3. The Diagnosis informs on the areas of need and supports medical necessity. 4. The Treatment Plan creates a framework for the services we provide. Together with client/family we develop goals and planned interventions that are meaningful and support their recovery. 5. Each Service is medically necessary and clearly related to an issue identified on a treatment plan through the assessment. Throughout the course of treatment, from assessment to discharge, all services must meet Medical Necessity. Meaning, every mental health service provided to the client/family is medically necessary to support the client/family in their path to recovery.

20 20 ASSESSMENT The assessment consists of the Psychosocial Assessment and the Mental Status Exam (MSE). The MSE is an important part of the comprehensive clinical assessment process. It is a way of documenting observations on the client s state of mind for a particular point in time. The psychosocial assessment is designed to provide a comprehensive clinical picture of the client, to establish medical necessity, to help treatment teams and clients define goals and objectives, and to fulfill State and Federal requirements. The information contained in the MSE, along with biological and historical information obtained through the assessment process informs the diagnosis. The psychosocial assessment provides the foundation for the delivery of services and establishes the need for mental health services to address impairments in the client s life domains. Among many things, a well-written assessment explores areas of need as well as strengths; it provides an opportunity to capture the essence of the individual; what is important to this individual, to his/her family, how culture factors in, how the individual sees themselves in relation to others/family/peers, clearly outlines mental health history and how mental health impacts their overall functioning, explores their past successes and shortcomings; and offers an opportunity to explore what meaningful goals they may have. Remember, it is extremely important to take the time to clearly document the information. Oftentimes, the treatment team may need to rely on the information in the psychosocial assessment when determining the next steps for the individual/family. One section that is often not fully explored is the strengths section on the assessment. You may want to pay special attention to the strengths section as this may help with identifying areas that can later be used for treatment planning. When looking at strengths, look beyond the traditional strengths. Strengths can include: Abilities and accomplishments Interests and aspirations Risk and Protective Factors Recovery resources and Developmental assets (such as a support team or WRAP plan) Unique individual attributes The information from the previous psychosocial will flow forward when writing an updated assessment. However, the practitioner is expected to ensure the updated assessment accurately reflects the client s current needs and establishes medical necessity. For clinical reasons, the information of the previously entered Clinical Summary and Recommendations sections do not flow forward. Note: At least one Psychosocial Assessments must be finalized on an annual basis. However, you may update the psychosocial assessment anytime you determine there is clinical relevance that is pertinent to the client s treatment. The California Code of Regulations 3 notes 9 items that must be included in an assessment: 1. Presenting Problem a. Changes in Functioning 2. Psychosocial Factors and Relevant Conditions a. Living situation and daily activities b. Legal history including any current issues and information and its influence current and past treatment c. Cultural and Linguistic factors d. Social support and/or family e. History of trauma or exposure to trauma 3 CCR, Title 9, section

21 21 3. Mental Health History a. Previous treatments dates, providers, therapeutic interventions and responses, inpatient admissions. If possible, include information from other sources of clinical data, such as previous mental health records, relevant family information, lab tests, and consultation reports. 4. Medical History a. Name of treatment provider, medications, dosages, dates of initial prescription and refills, and informed consent(s). b. Allergies and adverse reactions, or lack of allergies/sensitivities. c. For children and adolescents, history must include prenatal and perinatal events, and relevant/significant developmental history. You may include information from other sources of clinical data such as relevant family information and consultation records. 5. Substance Exposure/Substance Abuse a. Past and present use of tobacco, alcohol, and caffeine, illicit, prescribed, and over-the-counter drugs. 6. Client Strengths in achieving client plan goals 7. Risk Factors a. Situations that present a risk the beneficiary and/or others, including past and/or current trauma. 8. Special status situations additional clarifying formulation information 9. Mental Status Examination (MSE) Note: During the course of assessment and treatment, there may be information shared and/or observed by the clinician that is deemed pertinent for all staff to be informed of in order to safely engage the client in services. The clinician should enter this information in the Special Considerations section of the medical record. CANS AND ANSA Monterey County Behavioral Health uses the Child Assessment of Needs and Strengths (CANS) and the Adult Needs and Strengths Assessment (ANSA) as part of the assessment process. The CANS/ANSA are multi-purpose communication tools developed for child and adult services to support decision making, including level of care and service planning that allow for the monitoring of outcomes and goal attainment. The CANS/ANSA allows for the effective communication with the client/family to accurately represent the shared vision of the child and adult receiving services. Although the CANS/ANSA is a communication tool, we consider the information from the CANS/ANSA important when collaborating with the client in the development of their treatment goals. In AVATAR, the practitioner selects the age range for the client, which in turn activates the CANS/ANSA questions that are pertinent to the specified age group. CANS/ANSA uses a 4-level rating system where: 0= indicates no need for action. 1= indicates a need for watchful waiting to see whether action is needed. 2= indicates a need for action. 3= indicates the need for either immediate or intensive action. These levels are designed to translate immediately into action levels. From the scale above and as noted earlier, you can see how the information from the CANS/ANSA is useful in communicating the information to the client, especially for those items rated at a 2 and 3 that require action. As a practitioner, you may print the 114 -CANS/ANSA report and use it as a starting point in the collaboration process by identifying the needs and strengths of the individual and exploring what treatment and discharge may look like. A copy of the 114 report should also be given to the client/family. Note: CANS/ANSA must be completed at least on an annual basis.

22 22 CLINICAL SUMMARY The clinical summary is a very important part of the psychosocial assessment. It provides a broader understanding of the client beyond the assessment data. The summary is an opportunity for the practitioner to give their hunch or clinical impression about what is going on with the individual/family. The practitioner offers their interpretation of how all the information comes together and shares this hunch with the client. The summary also helps explain how the client s needs are identified and provides direction in treatment planning. The summary presents a holistic view of who the person and captures the person s essence. It includes barriers to the client achieving their life goals and strategies the individual has successfully used in the past to overcome barriers. A good summary leads with the client s strengths and it may include things like personal characteristics, strengths, motivations for behavior, past dreams, previous vocational and educational experiences or current desires. The summary is a paragraph or paragraphs written to integrate and interpret from a broader perspective, including all history and assessment information collected 4. The information cohesively reinforces medical necessity and clearly outlines how services will support the client s recovery. The Summary: Moves from what (data) to what does this mean and how do we use it? Sets the stage for prioritizing needs and goals. Basically: Family or client s story + Your clinical assessment = hypothesis or clinical summary. The summary of a psychosocial assessment moves from what (data) to why and provides a clear formulation for the diagnosis and treatment plan. The summary: Integrates and summarizes the data collected to include: Results from standardized tests Previous treatment experiences Discharge summaries Mental Status Evaluations Summarizes the perceptions of the client: Describes choices and prioritization Explains what s most important and what comes first Consistent with the individual and family s concerns/perspective Description of a central theme for the individual and family Identifies: Provides: The individual s strengths Personal/family values Cultural nuances Abilities and past accomplishments Interests and aspirations Resources and assets Unique individual attributes Identification of stressors /precipitants The foundation for developing goals and objectives by setting the stage for prioritizing needs and goals Behavioral descriptions of the needs and problems Identifies barriers to achieving desired goals Identifies co-occurring disabilities/disorders Recommends a course of treatment and determines the levels of care Specifics the state/phase of recovery Anticipates transition/discharge (length of service) Recommendations referrals, tests, special assessments as indicated 4 The Commission on the Accreditation of Rehabilitation Facilities (CARF). (2003). CARF Behavioral Health Manual, Tucson, AZ: CARF

23 23 Documents the recommended intensity of services. 5 The Narrative Summary functions as a bridge between the assessment and the treatment plan it explains why some, but not all, of the needs identified during the assessment become part of the treatment plan The summary includes: Informative findings based on assessment data and the subsequent recommendations Perception of the individual on his/her SNAP (strengths, needs, abilities and preferences) Perception of the provider on individual s SNARF (strengths, needs, abilities, risk and functional status) Provider insight into contribution and impact of individual s psychodynamic, cognitive, familial, environmental and personality traits on current status, service goals and treatment outcomes Elements of the Narrative Summary 6 Brief biographical data Brief overview of history of service Presenting problem Brief review of strengths Summary of medical necessity information Family and Environmental Supports Client s perception of the current situation Practitioner s view/opinion/impression Detail Age, gender, family of origin, spiritual/religious beliefs, relevant cultural background. Age of onset of symptoms, age at entry to mental health services, past services, trauma history, drug and alcohol use/abuse (as relevant). What is the current situation requiring assistance? What stressors are affecting the individual? Do not label the person as a diagnosis. Do mention symptoms the person is experiencing. Identified by the person, their family members, the provider, and natural supporters. Also identify environmental factors that will increase the likelihood of success. Recognize what motivates the person and identify what qualities can be used as strategies to promote goal achievement. For example positive peer support can decrease isolation. Barriers or functional impairments. How symptoms of the mental health diagnosis are making it difficult for the client to thrive at home, work, school, or in social situations? Family information, natural supports, community supports. Who are the people in the client s lives who have helped or could help them thrive? How the client sees their own needs, strengths, barriers. Use quotes if possible to express the client s perception. Why the client is unable to overcome existing barriers and requires services the hypothesis. The client may not share this viewpoint but we should share this clinical interpretation. 5 Adams, N. and Grieder, D. (2005) Treatment Planning for Person-Centered Care. Elsevier Academic Press. 6 Adams, N. and Grieder, D. (2005) Treatment Planning for Person-Centered Care. Elsevier Academic Press.

24 24 Client s desired result of treatment Stage of change Practitioner s recommendations for treatment What does the client want to work on? (both short and long term) Where is the client s motivation? Where is the client with the stage of change? Where would the client place themselves on the stage of change spectrum? What treatment modalities might be helpful to this person? What resources are needed? Recommended treatments, including any further/special assessments, tests, etc., as well as routine procedures (e.g. laboratory tests). The practitioner s recommendations may be different than what the client chooses to work on. This is where the practitioner documents their perspective or assessment of the client s need. SPECIAL CONSIDERATIONS During the course of assessment and treatment, there may be information shared and/or observed by the practitioner that is deemed pertinent for all staff to be informed of in order to safely engage the client in services. The Special Considerations form is used to communicate to the treatment team any special circumstances related to client s treatment. The special consideration form will allow the practitioner to include information regarding an active Safety Plan as well as other considerations. The Safety Plan section shall be used to communicate the active safety plan that is in place to help support the client s needs. The safety plan section will display at the top of the client notifications (green widget) section of the client chart overview. The safety plan will provide an opportunity to the treatment team to quickly view and understand the client s active safety plan and provide information on how to best support the client during this time. The form will allow the practitioner to enter a start and end date for the safety plan; only one active safety plan at a time is permitted. The other special considerations section will allow the practitioner to enter other important information or considerations related to the client s treatment. This section may include information about client s language needs, hearing deficits, gender identify preferences, mobility considerations, etc. Both, the Safety Plan and Other Considerations, will display in the client notification widget (green widget) section of the chart overview. When an active Safety Plan has been identified, the information about the safety plan will display on the top of the client notification widget. The information on other considerations will display at the bottom of the client notification widget. DIAGNOSIS/ ICD10 CODE SET The diagnostic formulation is based on the client s current and historical psychosocial assessment, where information of onset, symptoms, and level of functioning are determined. The accuracy of the diagnosis is important because it informs the clinical work. Only practitioner s whose Scope of Competence includes the ability to complete a diagnosis may do so. As a client begins services with behavioral health, all clients must have an Admission diagnosis with an ICD10 code set. Each new service episode of care includes an admission diagnosis. This diagnosis and an ICD10 must be present in order to submit claim for services. On the admission diagnosis, the diagnosis date defaults to the admission date of

25 25 the service episode. Do not change this date. The start date of the diagnosis must be the admission date of the specific service episode. Do not edit the admission diagnosis. A diagnosis with an ICD10 code set must be updated at least once annually. However, an Update diagnosis may be completed at any time in the course of treatment. In order to receive services, the primary diagnosis must be an Included Diagnosis with an ICD10 code set. The client may also receive services for an excluded diagnosis when the primary diagnosis is in the inclusion list. For example, when a mental health diagnosis and a substance use/abuse diagnosis are both present, the mental health diagnosis must be the primary diagnosis. Note: Specific programs may have population of focus; Consult with your supervisor. INCLUDED DIAGNOSIS A behavioral health client must have one of the following DSM-5 diagnoses which will be the focus of the intervention provided: Pervasive Developmental Disorders, except Autistic Disorder which is excluded Attention Deficit & Disruptive Behavior Disorders Feeding & Eating Disorders of Infancy or Early Childhood Elimination Disorders Other Disorders of Infancy, Childhood or Adolescence Schizophrenia & other Psychotic Disorders, except psychotic disorders due to a General Medical Condition Mood Disorders, except mood disorders due to a General Medical Condition Anxiety Disorders, except anxiety disorders due to a General Medical Condition Somatoform Disorders Factitious Disorders Dissociative Disorders Paraphilias Gender Identity Disorders Eating Disorders Impulse-Control Disorders, not elsewhere classified Adjustment Disorders Personality Disorders, excluding Antisocial Personality Disorder Medication-Induced Movement Disorders related to other included diagnoses DSM-5 implementation protocol and ICD 10 crosswalk for outpatient and inpatient EXCLUDED DIAGNOSIS Excluded Diagnoses A client may receive services for an Included Diagnosis even though an Excluded Diagnosis may also be present: 7 The following is a list of Excluded Diagnosis that cannot be the primary focus of clinical treatment: Mental Retardation Learning Disorders Motor Skills Disorder Communication Disorders 7 See the California Code of Regulations CCR, Title 9, Sections and for additional information.

26 26 Autistic Disorder, other Pervasive Developmental Disorders are included Tic Disorders Delirium, Dementia & Amnestic & Other Cognitive Disorders Mental Disorders due to a General Medical Condition Substance-related Disorders Sexual Dysfunctions Sleep Disorders Antisocial Personality Disorder Other conditions that may be a focus of Clinical Attention, except Medication Induced The presence of a non-eligible diagnosis does not impact the ability to provide treatment as long as there is a primary eligible diagnosis that is the focus of treatment. Practitioners are expected to include any substance diagnosis when warranted.

27 27 MEDICAL NECESSITY CRITERIA Medical necessity is established through the assessment process. Diagnosis and impairments further strengthen and reaffirm the need for mental health services that support the client/family s road to recovery. Although we establish medical necessity at assessment, it does not end there. Medical necessity permeates every service that is offered and delivered to the client/family and thereby, requires ongoing and continuous re-assessment throughout the client/family s course of treatment provided from Monterey County Behavioral Health To be eligible for Medi-Cal reimbursement for Outpatient/Specialty Mental Health Services, a service must meet all 3 criteria for medical necessity (diagnostic, impairment, & intervention related):

28 28 A. Diagnostic Criteria: The focus of the service should be directed to functional impairments related to an Included Medical Necessity It is not a one-time event. Medical necessity indicates our clinical impression that a client has impairments in their life functioning that would benefit from mental health treatment. We receive reimbursement for medically necessary services.

29 29 Diagnosis. B. Impairment Criteria: The client must have at least one of the following as a result of the mental disorder(s) identified in the diagnostic (A) criteria: 1. A significant impairment in an important area of life functioning, or 2. A probability of significant deterioration in an important area of life functioning, or 3. Children also qualify if there is a probability the child will not progress developmentally as individually appropriate. Children covered under EPSDT qualify if they have a mental disorder that can be corrected or ameliorated. C. Intervention Related Criteria: Must have all 3: 1. The focus of the proposed intervention is to address the condition identified in impairment criteria B above, and 2. It is expected the proposed intervention will benefit the consumer by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning; and/or for children it is probable the child will be enabled to progress developmentally as individually appropriate (or if covered by EPSDT, the identified condition can be corrected or ameliorated), 3. The condition would not be responsive to physical healthcare based treatment. All mental health services are provided based on medical necessity criteria, in accordance with an individualized Client Plan, and approved and authorized according to State of California requirements. 8 Clearly, it is possible that some clients will not meet medical necessity criteria. When this is determined, practitioners should consult with their supervisors to identify appropriate referrals. Practitioners should then complete a Notice of Action (NOA). 8 State Plan Amendment # Rehabilitative Mental Health Services

30 30 NOTICE OF ACTION ASSESSMENT A Notice of Action (NOA) is entered when it is determined that a client is not eligible for services or there has been an alteration in the services provided. 9 Before completing a NOA, practitioner should consult with supervisor. What is a Notice of Action (NOA) and what is its purpose? A Notice of Action is a document given to a client whenever any of the following occurs: A NOA is used when the county or its providers assess a beneficiary and decide the beneficiary does not meet medical necessity and no specialty mental health services will be provided. Not meeting medical necessity means any of the following: 1. That the beneficiary does not have a diagnosis covered by the county mental health plan (an included diagnosis). 2. That a beneficiary who is 21 or over has an included diagnosis, but doesn't have a significant impairment. 3. That a beneficiary who is under 21 years of age has an included diagnosis, but there is no covered intervention that will correct or ameliorate the condition. 4. That the beneficiary has an included diagnosis, but the condition would be responsive to physical health care based treatment. When determining a client is not eligible for services, practitioners should consult with their supervisor. The Notice of Action is important because it is used to advise the beneficiary of the action taken and to provide information to the beneficiary on their right to appeal the decision. 10 In Monterey County, all NOA s are entered in the electronic medical record. The Notice of Action Assessment form records the date of the decision, the practitioner making the decision, and the decision. It must be completed as soon as the action is taken. The data elements on this form include: Date of the decision: This field should indicate the date the decision was made that the client needs an adjustment in services provided. Date of Letter: This field should indicate the date the letter will be sent to the client. This field will be shown in the letter generated for the client. Decision: The decision field indicates one of the following options Not covered- Your mental health diagnosis as identified by the assessment is not covered by the mental health plan (CCR, Title 9, Section (b)(1)). Not eligible- Your mental health condition does not cause problems for you in your daily life that are serious enough to make you eligible for specialty mental health services from the mental health plan (CCR, Title 9, Section (b)(2)). No improvement- The specialty mental health services available from the mental health plan are not likely to help you maintain or improve your mental health condition (CCR, Title 9, Section (b)(3)(a) and (B)). Not responsive- Your mental health condition would be responsive to treatment by a physical health care provider (CCR, Title 9, Section (b)(3)(c)). Practitioner completing NOA: This field should indicate the practitioner completing the notice of action assessment. 9 CCR, Title 9,Chapter 11, Section Sections 5777, 5778, and 14684, Welfare and Institutions Code and Title 42, Code of Federal Regulations, Part 438, Subpart F.

31 31 Once the NOA assessment form has been completed, the practitioner should run the Notice of Action Assessment Report available in AVATAR. This report will generate a letter, in an approved format, that must be provided to the beneficiary where it indicates what decision was made. This form should be mailed to the beneficiary along with the second page of this report which explains the beneficiary s rights to appeal the decision made by the mental health plan. Beneficiaries shall be informed of their right to file an appeal if they do not agree with the proposed action. The NOA shall be hand delivered or put in the mail no later than the third working day after the action was taken. 11 Whenever possible, the staff shall make all appropriate efforts to assist the beneficiary in preparing for the proposed action, including, but not limited to, pointing out alternate resources and/or support such as self-help groups and other community services. Also, the beneficiaries shall be advised, where appropriate, that they may become eligible for an increased level of services if their condition worsens. And, inform the beneficiary that she/he will not be subject to any discrimination, penalty sanction, or restriction, for filing a complaint. Note: Remember to document your services in a progress note. FREQUENTLY ASKED QUESTIONS ABOUT THE NOTICE OF ACTION POLICY Who receives a copy of the NOA? All NOA s are given to the beneficiary. Is the NOA still addressed to the beneficiary when the beneficiary is a minor? Unless it is a minor consent case, the original should be sent to the minor and a copy should be sent to the minor s parent or legal guardian. For minor consent cases, the NOA should be handled in one of the following ways: 1. Given to the minor in person 2. Given to the minor s eligibility worker to give to the minor next time s/he comes in 3. Held by the practitioner until the next time the minor comes into the office/clinic. In minor consent cases, the NOA must not be mailed to the minor s address and the minor s parent/guardian must not receive a copy or be otherwise notified. When do I give the NOA to the client? With exceptions, the NOA must be hand delivered or put in the mail no later than the third working day after the action was taken. Must a NOA be issued when a network provider does an assessment and determines the beneficiary does not meet medical necessity? Yes. The beneficiary must be provided an NOA regardless of whether the assessment is completed by the COUNTY or its providers. Must a NOA be issued when a beneficiary calls for general information about services? No. If only general information about available services and/or the County s authorization process are discussed. However, a NOA would be required if some sort of screening takes place and, as a result, it is determined that the client does not meet medical necessity. We need to be very careful in this area. A caller to the toll-free access number or to one of our clinics should not be hastily turned away just because the caller mentions alcohol or substance abuse problems. It is strongly recommended that, when in doubt, a face-to-face assessment should be arranged. Must a NOA be issued every time a beneficiary requests a service that the county has decided is not medically necessary? No. The county has to issue a NOA to a client after an assessment has been completed, and it is determined that the beneficiary is not eligible for any specialty mental health service from behavioral health. 11 Behavioral Health Policy Number 120

32 Must a NOA be issued when a provider determines that a reduction or termination of services is needed? No, since the reduction or termination is being made by the provider rather than the county s point of authorization. NOA requirements do not apply to direct clinical decision-making. However, the beneficiary still has the same appeal and fair hearing rights as if the beneficiary were given a NOA. Can we simply issue a NOA when the county does not provide a particular specialty mental health service the client needs? No. If we determine the beneficiary is in need of a particular specialty mental health service, we have an obligation to provide or arrange for that service. The issuing of an NOA does not excuse behavioral health from meeting its contractual obligation to provide medically necessary specialty mental health services to its beneficiaries. Must a NOA be issued if the county offers a specialty mental health service, but not necessarily the service requested by the beneficiary? No. However, the beneficiary must participate in the development of the client plan. The county should ensure that services, to the extent possible, are client directed. A client who believes additional services are necessary has the right to challenge the county and provider decisions through the beneficiary appeal and state fair hearing processes. Must a NOA be issued when the beneficiary is not approved for a service he/she has requested? No, unless the county determines that no specialty mental health services will be provided. Must a NOA be issued if a treatment team determines a lack of medical necessity? Yes. An NOA is required for decisions by the county or its providers. The treatment team, acting as a provider, is deciding that the beneficiary will not receive services from the county. Must a NOA be issued when a beneficiary, who originally asked for services, changes his/her mind during the assessment process and, as a result, no services were offered? No, assuming the decision that services are not necessary was made by the beneficiary. The trigger for an NOA is the decision by the county or its providers that no services are needed. When the county or its providers explain to the beneficiary why no services are needed and the beneficiary then agrees, an NOA is required. Is an assessment to determine medical necessity considered a specialty mental health service? In particular, if a beneficiary is found to not meet medical necessity criteria after a few assessment sessions or by the end of the assessment period, do we need to issue a NOA? Yes. The county needs to issue a NOA, if a beneficiary is found not to meet medical necessity after a few assessment sessions or by the end of the assessment period. An assessment to determine medical necessity is a specialty mental health service covered by the county. A beneficiary does not need to meet medical necessity to receive such an assessment. (See CCR, Title 9, Section ) The NOA applies to a determination that future services will not be provided because the beneficiary being assessed does not meet medical necessity. 32

33 33 Chapter 5 DISCHARGE PLANNING It is the practitioner s responsibility to begin the discussion of discharge planning as early as the onset of services. It is pertinent to take the time to learn about what discharge may look like for the client/family as this will further inform goal development. Discussion of discharge helps not only lays the foundation for treatment planning, but more importantly conveys the possibility of recovery and instills hope in the individual/family seeking services. Discharge from services can occur as a result of a number of issues, including: Goal attainment Client s determines he/she no longer is interested in receiving services Client s needs may be better treated in a different setting Client moved out of County Client is in a long term setting, such as incarceration and skilled nursing Death * Whenever possible, discharge from mental health services should be done in conjunction with the client. However, we understand that there may be times when a client/family decides to drop-out of treatment with little notice or without notice at all. When this occurs, the practitioner should work with the treatment team on appropriate next steps such as a discussion about a reasonable outreach plan, which may include writing a letter, telephone calls, and/or home visits, if warranted. The practitioner is responsible for reasonable outreach efforts and these efforts must clearly be documented in the client s medical record in order to maintain accuracy of the client s medical record. Once determined that reasonable outreach efforts have been made, the client is no longer interested in continuing services, and/or in the event the client cannot be located, it is the Coordinator s responsibility to complete the discharge process. We strongly encourage the Coordinator/Practitioner to consult with the treatment team and/or their supervisor prior to discharging a client from services. To complete the discharge process, the Coordinator must complete the following: Ensure all progress notes are finalized (you may run report 304) Close out treatment goals on Client Treatment Plan Complete a progress note, which includes a treatment summary Add an end date to the Client Care Coordinator form Complete the Discharge form for your program Inform other service providers involved with treatment (psychiatrist/community programs/nurses, etc.) Note: You may want to use the Pre-Discharge option to ensure all documents and necessary steps are completed prior to completing the discharge form. This option will check the medical record for notes in draft status, discharge diagnosis, client case coordinator, and future appointments. This option is located within the discharge form (Search Discharge>select Program>select Pre-Discharge form the sections on the left>pre-discharge Check List). Note: Time spent developing care discharge plans should be claimed as Case Management (301). Once the discharge from services is complete, no progress notes may be submitted to the closed episode. There is no minimum amount of time a client must remain opened for services prior to discharge. *In the event of a death of a client. Please work closely with your Supervisor for added support during this often difficult situation. As soon as feasible possible, please complete an Unusual Incident Report and follow all procedures outlined in MCBH Policy 123. Immediately upon knowledge of the client s death, any outstanding progress notes may be written using a non-billable service code. Please remember to continue to uphold confidentiality of client s records.

34 34 Chapter 6 CLIENT-CENTERED CARE & TREATMENT PLANNING As a behavioral health system, Monterey County is committed to delivering client and family driven care. Clientcentered care has been recognized as a best practice in mental health. All services and programs designed for persons with mental disabilities should be consumer centered, in recognition of varying individual goals, diverse needs, concerns, strengths, motivations, and disabilities. 12 Client-centered care involves putting the consumer in the driver s seat of the care they are receiving. Client reaches Goals We provide interventions that help the client reach their goal We develop objectives or steps the client can take to reach their goal We evaluate the strengths clients can use to achieve goals We work with the client to identify and prioritize goals We conduct an Assessment to help develop understanding of the problem Client Asks for Help {or in a mandated program someone else asks you to help the client} 12 W&l Code

35 35 FAMILY DRIVEN CARE When serving children, we strive to be a family-driven system of care that fosters resiliency. The chart below demonstrates some differences between traditional care and client/family-driven care services. Traditional Care Practitioner Based Problem Based Professional Dominance Cure and or Amelioration Dependence Reactive Professional Supports Client/Family Driven Care Client/Family Directed Strength Based Skill Acquisition Quality of Life Empowerment Preventative and/or Wellness Natural Supports Resilience refers to the personal qualities of optimism and hope, personal traits of effective problem solving skills that lead individuals to live, work and learn with a sense of mastery and competence. Research has shown that resilience is fostered by positive experiences in childhood at home, in school and in the community. When children encounter negative experiences at home, at school and in the community, mental health treatments, which may teach good problem solving skills, optimism, and hope that may help build and enhance resiliency in children Families and youth are given accurate, understandable, and complete information necessary to set goals and to make choices for improved planning for individual children and their families. 2. Families and youth, providers and administrators embrace the concept of sharing decision-making and responsibility for outcomes with providers. 3. Families and youth are organized to collectively use their knowledge and skills as a force for systems transformation. 4. Families and family-run organizations engage in peer support activities to reduce isolation, gather and disseminate accurate information, and strengthen the family voice. 5. Families and family-run organizations provide direction for decisions that impact funding for services, treatments, and supports. 6. Providers take the initiative to change practice from provider-driven to family-driven. 7. Administrators allocate practitioner, training, support and resources to make family-driven practice work at the point where services and supports are delivered to children, youth, and families. 8. Community attitude change efforts focus on removing barriers and discrimination created by stigma. 9. Communities embrace, value, and celebrate the diverse cultures of their children, youth, and families. 10. Everyone who connects with children, youth, and families continually advances their own cultural and linguistic responsiveness as the population served changes. 13 Source: California Family Partnership Association, March 2005

36 36 STRENGTHS Our goal is to reduce symptoms by increasing strengths and coping skills in order to help people live a meaningful life in the community. What are strengths? Environmental factors that will increase the likelihood of success such as: Strengths Community supports, family/relationships, support/involvement, work, etc. May be unique to racial, ethnic, linguistic and cultural (including lesbian, gay, bisexual and transgender) communities Identifying the person s best qualities/motivation Strategies already utilized to help (what worked in the past) Competencies/accomplishments interests and activities, i.e. sports, art identified by the consumer and/or the provider Motivated to change Has a support system friends, family Employed/does volunteer work Has skills/competencies: vocational, relational, transportation savvy, activities of daily living Intelligent, artistic, musical, good at sports Has knowledge of his/her disease Values medication as a recovery tool Has a spiritual program/connected to a church Good physical health Symptoms Adaptive coping skills/ help seeking behaviors Capable of independent living Use the information from the assessment on strengths (including cultural strengths) to identify the individual/family attributes and skills. Identify resources that will be particularly significant to supporting the client in achieving their goals. When considering strengths, it is beneficial to explore other areas not traditionally considered strengths. Such examples include: an individual s most significant or most valued accomplishment, what motivates them, educational achievements, ways of relaxing and having fun, ways of calming down when upset, preferred living environment, personal heroes, most meaningful compliment ever received, etc. 14 We want to take the time to acknowledge the value of the individual s existing relationships and connections. If it is the individual s preference, significant effort should be made to include these natural supports and unpaid participants as they often have critical input and support to offer to the treatment team. Treatment should complement, not Strengths are not just something we list on an assessment. The client s strengths are utilized in every part of treatment process. -We identify strengths in the assessment -We then set goals to build on strengths in the treatment plan -The progress notes help us show how our interventions help build up the strengths that help individuals thrive. interfere with, what people are already doing to keep themselves well, e.g., drawing support from friends and loved ones Implementation of person centered care and planning: how philosophy can inform practice J Tondora, S Pocklington, A Gregory Jones. Yale University School Yale Program for Recovery and Community Health Department of Psychiatry, Yale University School of Medicine. 15 Osher, T., & Osher, D. (2001). The paradigm shift to true collaboration with families. The Journal of Child and Family Studies, 10, (3),

37 TREATMENT PLAN A treatment plan is a document, co-created by the client and the provider, which outlines the steps needed to achieve particular goals or outcomes based on the information contained in the psychosocial assessment and informed by the diagnosis. Monterey County Behavioral Health is committed to providing client-centered care. This commitment is shown when our mental health practitioners engage clients in the development of a meaningful treatment plan. The treatment plan is the primary way we empower the client/family to develop a plan to achieve their recovery and resiliency goals. The treatment planning process supports clients in understanding what they can expect from the behavioral health services we provide and their own role in their recovery. We embrace the obligation of providing clients with the most effective treatment and use of evidenced-based care available to help clients reach their personal goals and thrive in their community. Monterey County embraces the One-Treatment Plan model for the delivery of services. This means that all programs, whether from MCBH programs or community partners, co-create treatment goals with the client/family to help them achieve their goals. This model helps the client understand who is providing what services and more specifically, what the expectations are from everyone. This understanding extends to writing treatment plans in the client s primary/preferred language alongside the English version. Research clearly shows the importance of practitioners investing time to support consumers in making educated decisions about the care they receive. 16 Without developing client friendly treatment plans, research shows we fail to retain consumers who feel they have not developed a shared vision of success with their practitioner. 17 A treatment plan should be like a roadmap to success. We join with our clients to develop an understanding of where they are and where they want to arrive. Then we plot out a map of how we, as mental health providers, can help them reach their goals. The treatment plan was recognized as the core to clients reaching their recovery goals by the Presidents New Freedom Commission who noted: An individualized plan of care will give consumers, families of children with serious emotional disturbances, clinicians, and other providers a valid opportunity to construct and maintain meaningful, productive, and healing relationships. Opportunities for updates based on changing needs across the stages of life and the requirement to review treatment plans regularly will be an integral part of the approach. The plan of care will be at the core of the consumer-centered, recovery-oriented mental health system. The plan will include treatment, supports, and other assistance to enable consumers to better integrate into their communities; it will allow consumers to realize improved mental health and quality of life. 18 Our Vision: Let s make a treatment plan that is so low stigma a person could place it on their refrigerator. When they read the plan they will feel hopeful like behavioral health is helping them get the tools they need to thrive. As you start to develop a treatment plan, don t focus on what is a problem, goal, objective, or intervention. Start first with why are we treatment planning? Although we find the fiscal consequences of audit exceptions when we don t have a treatment plan quite 16 Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Services Research 2010, 10:26 17 Shared Decision Making in Public Mental Health Care: Perspectives from Consumers Living with Severe Mental Illness. Psychiatric Rehabilitation Journal Issue: Volume 34, Number 1 / Summer Achieving the Promise: Transforming Mental Health Care in America. The President s New Freedom Commission on Mental Health.

38 38 motivating our real reason for completing a treatment plan is the opportunity to develop a shared vision of success with our clients and their families. At least once a year we have the chance to join with our clients to ask the following questions. Why are you here, what do you want, and how can we help you get it? If we find ourselves unable to ask or answer these questions then we need to look closely at medical necessity are the services we are providing necessary for this client? Are the services helping to reduce risk and improve functioning? All services need to be medically necessary and must be treating symptoms of an included diagnosis. It is the responsibility of the Care Coordinator to work with the client and any providers to ensure that the client receives agreed upon services that will help reduce the barriers/impairments resulting from their mental health condition. Remember, without the opportunity to develop a meaningful treatment plan, we lack a measurement to define the success our clients deserve. Program goals should be consistent with the client s/family s goals as well as the diagnosis and assessment. The client s participation and understanding of all elements of the plan is essential and is expected by our auditors and is mandated by state regulations. W&I Code Sec (a)(2) states: (Persons with mental disabilities) Are the central and deciding figure, except where specifically limited by law, in all planning for treatment and rehabilitation based on their individual needs. Planning should also include family members and friends as a source of information and support. This regulation indicates that unless a person has a legal status that removes the client s decision making power, the client must fully participate in the treatment plan. At a minimum, client participation is documented by obtaining the Client Treatment Plan Participation Consent. Obtain the signature of the client/parent/guardian and provide a copy of the plan to the client/family member. 19 Giving a copy of the plan to the client/family member is an important acknowledgment of their participation in its development and of the practitioner s commitment to involving our clients. Remember, treatment plans must be co-created and whenever possible written in English followed by the client/family s primary/preferred language in order to encourage goal attainment. As you begin treatment planning, it is important to consider the client s stage of change. The treatment plan should be reflective of the client s current stage of change or willingness for change. Even for those individuals who are referred and/or mandated to treatment or when their illness acts as a barrier to insight, we must include them in the treatment planning process. Treatment planning does not work when we are not willing to work alongside the client on the development of goals that are meaningful to them. Maintenance Pre- Contemplation Action Contemplation/ Preparation Mental health treatment will look different based on the client s stage of change. For example, if a client is experiencing symptoms of depression and they are in a pre-contemplation stage of treatment, services will not target removal of symptoms. For this client we might start with assessing how the symptoms of depression are impacting their life. If a client was in the action stage of change, treatment might likely involve active cognitive skill building to address these symptoms. Remember, it a possible for a client to be on different stages of change for different issues. 19 As required by CCR, Title 9, sections and (c)

39 Below are two models of the stages of change, suggested stage of treatment, and potential treatment focus. 1: Village 2: Prochaska & DiClemente Stage of Treatment Treatment Focus 20 High Risk/ Unidentified or Unengaged Pre- Contemplation Engagement Outreach Practical help Crisis intervention Relationship building Poorly Coping/ Engaged/Not Self-Directed Contemplation/ Preparation Goal Development Psycho-education Set goals Build awareness Coping/Self- Responsible Action Active Treatment Counseling Skills training Self-help groups Prevention plan Graduated or Discharged Maintenance Relapse Prevention Skills training Expand recovery DETAILS ON STAGES OF CHANGE Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future. Most individuals in this stage are unaware or under-aware of their problems. Families, friends, neighbors, or employees, however, are often well aware that the person is struggling. When people in the Precontemplation stage present for service, they often do so because of pressure from others. Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action. Individuals can remain stuck in the contemplation stage for long periods. Individuals in the contemplation stage would be endorsing such items as, "I have a problem and I really think I should work on it" and "I've been thinking that I might want to change something about myself." Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year. Action is the stage in which individuals modify their behavior, experiences, and environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy. Modifications of the 20 Adams, N. and Grieder, D. (2005) Treatment Planning for Person-Centered Care. Elsevier Academic Press.

40 40 problem behavior made in the action stage tend to be most visible and receive the greatest external recognition. Individuals are classified in the action stage if they have successfully altered the dysfunctional behavior for a period from 1 day to 6 months. Individuals in the action stage endorse statements like, "I am really working hard to change" and "Anyone can talk about changing; I am actually doing something about it." Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. Being able to remain free of the problem behavior and to consistently engage in a new incompatible behavior for more than 6 months are the criteria for considering someone to be in the maintenance stage. Individuals in the maintenance stage might say, "I may need a boost right now to help me maintain the changes I've already made" and "I'm here to prevent myself from having a relapse of my problem." Assess the client's stage of change. Probably the most obvious and direct implication of the research evidence is the need to assess the stage of a client's readiness for change and to tailor therapeutic relationships and interventions accordingly. Beware of treating all clients as though they are in action. Professionals frequently design excellent actionoriented treatments, but then are disappointed when only a small percentage of clients remain in therapy or treatment. The vast majority of clients are not in the action stage. Aggregating across studies and populations, we estimate that 10% to 20% are prepared for action, approximately 30% to 40% are in the contemplation stage, and 50% to 60% in the Precontemplation stage. Thus, those professionals with only action-oriented programs are likely to under serve or misserve the majority of their target population. Set realistic goals. Move one stage at a time. A reasonable expectation for many clients is to set initial goals, such as progressing from Precontemplation to Contemplation. Such progress means that clients are changing. We view change as a process that unfolds over time, through a series of stages. Helping clients break out of the stuck phase of Precontemplation is a therapeutic success, since it about doubles the chances that clients will take effective action within the next 6 months. If we can help them progress two stages with brief therapy, we triple to quadruple the chances they will take effective action. 21 COMPONENTS OF THE TREATMENT PLAN Treatment Plan Dates: Treatment Plan Start and End dates coincide with the original date of coordination. The Treatment Plan dates run for the course of one-year. As an example: If the original date of coordination is February 15, 2012, then the initial Treatment Plan (MCBH 2012) dates are 2/15/2012-1/31/2013. This initial treatment plan will be finalized. This means the plan can no longer be edited, so a draft plan will need to be created to add/update goals. In the event that the client is opened for services with another program during this same year (let s say another episode opened on 5/3/12) the adjunct program will enter treatment goals. All goals will show the date the goals were created. These dates coincide with the dates for which the client receives services within the program(s). In our example above, the individual goals for the adjunct program would reflect the 5/3/2012 date. Please note: as the client achieves their particular goals or is no longer interested in working on a particular goal, it is the responsibility of each program to close out the program s treatment goals by entering the date the goal was closed and/or completed on the treatment plan. 21 Stages of change. Prochaska, James O.; Norcross, John C. Psychotherapy: Theory, Research, Practice, Training, Vol 38(4), Win 2001,

41 41 As of June 2014, all treatment plan dates have been automated and automatically displays the start and end date in accordance with the original date of coordination. So, using the above example, during the client s annual review period, the annual treatment plan dates will automate to (MCBH 2013) 2/1/2013 1/31/2014. It is important to finalize the treatment plan and then generate a draft plan which will function as a living document. The draft plan can be updated throughout the course of treatment to accurately reflect the needs and goals of the client/family. This includes updating the dates on the specific Problem, Goal, Objectives, and Interventions for those goals which the client intends to continue to work on achieving. MY LIFE GOALS/ASPIRATIONS (IN CLIENT S OWN WORDS) This statement is located at the beginning of the treatment plan and it is intended to be a space where the client s goals are freely stated. This space may indicate the client s desired outcome of successful treatment. This is the reason the client is seeking treatment. Overall goals are broad life goals, such as returning to work or graduating from high school. The overall goal is meant to be a global objective that reflects the client s intent and interests. The overall goal should be clear to the client and the treatment team, and it should reflect the client s preferences and strengths. These goals have a special place in a system committed to recovery and resiliency they should speak to the client s ability to manage or recover from his/her illness and achieve major developmental milestones. Reminder: treatment plans written in both, English and the client/family s preferred language, support the client s increase understanding of treatment and encourage participation goal attainment. MY CHALLENGES/BARRIERS (PROBLEM) This is a statement of the behavioral signs and symptoms of the primary diagnosis and other barriers and/or challenges in the individual s life domains. This statement is the focus of treatment. Remember: The problem is not the diagnosis--the problem is the symptoms, of the diagnosis, that prevent the client from living the life they want. It may take time to build an understanding with our clients about the symptoms/challenges/barriers they may be experiencing. However, as part of the informed consent process, the practitioner joins with the client (and possibly their family) to share their clinical perspectives. Working with the client, the practitioner and the client can develop a shared understanding of the problems that can benefit from treatment. Our role as practitioners is to help our clients understand how the symptoms of the diagnosis might be interfering with reaching their goals.

42 42 MY HOPES/GOALS Goals build upon the strengths, preferences, and needs of the client. Goals should embody hope. Practitioners need to be mindful that identifying a goal to a practitioner can be frightening to a client, child or family. Sharing one s aspirations with another can make people feel vulnerable 22. A practitioner may help the client start thinking about their goals by asking the Miracle Question If you woke up tomorrow and all was well, what would that look like? A goal is stated in the clients own words and relates to a quality of life goal. For example, I want a car; I want to go back to school to get a degree; I want a girlfriend/boyfriend; I want to get off of SSI and be self-sufficient. The goal is the development of new skills/behaviors and the reduction, stabilization or removal of the barrier/problem. Individual goals are generally related to important areas of functioning affected by the client s mental health condition, such as living situation, daily activities, school, work, social support, legal issues, safety, physical health, substance abuse, and psychiatric symptoms. The assessment must clearly document how a particular goal reflects the client s mental health condition. Note: Writing too many goals can make a treatment plan overwhelming and unwieldy to both practitioner and the client. 23 By consolidating goals the treatment plan can have greater focus and clarity. A goal should be a shared vision of success. Goals express the hopes and dreams of the consumer. Goals identify the hoped-for destination to be arrived at through the services provided. Person- centered goals are: Ideally expressed in the words of the individual, their family and/or other supportive individuals. Easily understandable in the clients preferred language (document completed in English followed by primary/preferred language) Appropriate to the person s culture; reflect values, traditions, identity, etc. Consistent with desire for self-determination and self-sufficiency and may be influenced by culture, tradition and sense of community Written in strengths-based language Consistent with abilities/strengths, preferences and needs Embody hope/alternatives to current circumstances 24 MY ACTION STEP (OBJECTIVES) Objectives are the smaller accomplishments or the steps the client/family will need/want to make in order to achieve their goal. The objectives are used to address an already identified issue in the psychosocial assessment and the challenge statement. They are specific to a mental health barrier or functional impairment and are measurable. This is a breakdown of the goal in accordance with their stage of change. It may include specific skills the client will master and/or steps or tasks the client will complete to accomplish the goal. Objectives should be specific, observable, or quantifiable and are related to the assessment and diagnosis. A simple mnemonic that may be helpful when working with the client to develop program objectives is SMART (Specific, Measurable, Attainable, Realistic, Time-Framed). SMART Objectives: Specific Measureable Attainable Realistic Time-Framed Objectives need to be: 22 Transformational Care Planning. Module 4: Developing a Family Driven Plan of Care 23 Adams, N. and Grieder, D. (2005) Treatment Planning for Person-Centered Care. Elsevier Academic Press. 24 Transformational Care Planning. Module 4: Developing a Family Driven Plan of Care

43 43 Appropriate to the setting/level of need/stage of change. Responsive to the person or family s individual abilities and challenges. Appropriate for the person s age, development and culture. Quantifiable and time limited. Objective Subject (client) Action Word What When Measurement The diagram above demonstrates possible ways to break down a concise measureable objective. Here is a case example: Jessica is a 15 year old girl Jessica and her mother came to the county for help with her anxiety issues Jessica is anxious about being in school She has low self-esteem and feels her peers do not like her She feigns illness frequently to avoid going to school Sometimes she comes home from school early or skips altogether, returning home after her mother leaves for work Jessica and her mother fear she will fail her classes because of absences Subject (client) Action Word What When Measurement Objective Jessica will manage anxiety by using coping skill of deep breathing once a day in response to anxiety for 6 months as reported by herself in therapy sessions.

44 44 Subject Client Action/ Verb Will increase What Use of his strength of social connectedness or activity with peers when he/she feels down When? Weekly over the next 6 months How will it be measured? Client and family report during sessions How specific, observable, measurable should objectives be? Specific, observable, and measurable enough so that both, you and the client, are likely to agree on the point in time when the objective/goal is achieved. The focus of the objective is the actual demonstration of new skills and/or abilities. When? Not all objectives should be based on a year timeline. The client s annual plan my involve planning for one year but the timeframe of an objective should be specific to the person s needs. The client should have enough time to work through meeting their objectives, but not make it so long that the client/family has little opportunity for smaller successes along the way. Note: The objectives must relate back to an identified problem/challenge/strength noted in the psychosocial assessment and the challenge statement.

45 45 SUPPORTS (INTERVENTIONS) Interventions are the things the practitioners will do in order to assist the client to meet his/her objectives and eventually the life goal(s). These interventions are mental health interventions and relate back to the challenge/problem statement. They answer the five W s: Who: Clinical discipline of practitioner (e.g., Care Coordinator, practitioner, case aide) What: When: Where: Why: Modality/Service provided Frequency/intensity/duration Location Purpose/intent/impact The interventions are why we receive reimbursement from Medi-Cal. All proposed interventions must meet the medical necessity criteria. Meaning the proposed intervention will benefit the consumer by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning; and/or for children, it is probable the child will be enabled to progress developmentally as individually appropriate; or if covered by EPSDT, the identified condition can be corrected or ameliorated. Additionally, interventions define the concrete strategies/actions that will be utilized to assist the client/family in meeting the objectives. Keep in mind that you can have multiple interventions (different service types) for the same problem/goal/objective cluster. Service types often include: medication services, group counseling, individual counseling, case management, and for the full service partnership clients, intensive case management. Each intervention needs to be specific and non-duplicative. Example of UNACCEPTABLE documentation of an intervention: Case management as needed for the next year Group services for 12 months Medication support Example of an ACCEPTABLE documented intervention: Practitioner will provide case management services twice monthly for the next year to support the client in maintaining current residential placement. Practitioner will facilitate the XYZ group weekly for the next six months to help reduce her feelings of isolation Psychiatrist will meet with Jason every six weeks for medication support visits to ensure medication is still helping his feelings of anxiety. Explanation of acceptable documentation: In the acceptable intervention we have written something that is specific and will help the client to understand our intended services This intervention has a specific group and duration. This is specific and clear. Jason could read this intervention and know why medication support may help him. Clinic Nurse will meet with Jason every 4 weeks and will provide medication support and injection to alleviate (specify symptoms).

46 46 COMPONENTS OF A GOOD TREATMENT PLAN Clinically Relevant: The plan clearly outlines needs identified in the assessment. Culturally Relevant: The plan should take into account all types of cultural issues to arrive at a meaningful understanding of the client s worldview. These considerations include ethnicity but are expanded to include family of origin, traditions and holidays, religion/spirituality, education, work ethic etc. Whenever possible, the plan should be written in English followed by client/family s preferred language. Client-Centered: The plan should be written in a way that is culturally sensitive and personally relevant. The plan is developed in collaboration with the client and uses language that is understandable and is acceptable to the client. Strengths-Based: The plan identifies strengths of the individual and utilizes client strengths to reduce barriers. The plan focuses on the person s competencies as well as what the person needs to do to overcome impairments. Real: A good treatment plan meets and reflects where the client is in their lives/recovery. If a client is early in their stage of change we want to make sure to write goals that reflect this stage and avoid writing goals in a different stage making it extremely difficult to achieve. Remember, start where the client is.

47 47 Chapter 7 PROGRESS NOTES It is critical for all practitioners to be aware that they have an essential role to play in ensuring the compliance of our services with all pertinent state and federal regulations. The progress note is used to record the services that result in claims (billing). Please remember that when you write a billable progress note you are submitting a bill to the State. Therefore, all progress notes must be accurate and factual. Errors in documentation (e.g., using an incorrect location or service charge code) directly affect our ability to submit true and accurate claims. For this reason, compliance is the personal responsibility of all clinical and administrative staff. What makes a good progress note? A good progress note accurately represents the services provided. Each progress note needs to stand alone to justify the mental health service provided. This means that each progress note must clearly identify a mental health intervention. Every billable service must be medically necessary. Medical Necessity is established by ensuring that interventions meet ALL three (3) criteria below: 1. The focus of the proposed (mental health) intervention is to address the condition identified in impairment criteria for the included diagnosis, and Who are we writing the note for? Progress notes should be written as if an attorney and/or the client/family will read the document. You should be able to explain or defend every statement that is made in the progress note. Use quotes when stating what other people said. 2. It is expected the proposed intervention will benefit the consumer by significantly diminishing the impairment or preventing significant deterioration in an important area of life functioning; and/or for children it is probable the child will be enabled to progress developmentally as individually appropriate (or if covered by EPSDT, the identified condition can be corrected or ameliorated), and 3. The condition would not be responsive to physical healthcare based treatment. You may ask yourself, how the proposed intervention may help the client improve or support the person in maintaining his/her important areas of life functioning? In what ways do I expect this intervention to support the individual in improving or addressing those important areas of life functioning? Remember, for reimbursement of a medically necessary service, the intervention must: 1) Be a mental health intervention 2) Address an issue identified in the assessment 3) Relate back and link to a treatment plan goal (previously identified issue on the assessment) 4) Clearly identify how the intervention supports or improves the individual s life functioning Monterey County Behavioral Health requires that practitioners use a FIRP format for all progress notes. This format helps ensure that all the requirements of the note are met. Use your judgment about what to include. Progress notes are used to inform the on-duty practitioner and other clinical staff about the client s treatment, to document and claim for services, and to provide a legal record of services provided. Progress notes may be read by clients/family members and should be written in a manner that supports client-centered, recovery-based, and culturally competent services. Aim for clarity and brevity when writing notes lengthy narrative notes are discouraged. Never copy and paste notes into a client s medical record. Not only does this practice do a disservice to the individual s documented course of treatment; it is an unethical practice. Each note must clearly document the specific service provided as well as capture the individual/family response to the intervention.

48 48 If two or more practitioners are providing a service to a client, each person needs to document their own unique intervention during the service. While one practitioner may reference another s note, both practitioners need to indicate an intervention provided. Clear and concise documentation is crucial to client care. Progress notes are used, not only to claim for services, but to document the client/family s course and progress in treatment. Progress notes should clearly indicate the type of service provided, how the service is medically necessary to address an identified area of impairment, and the progress (or lack of progress) in treatment. It is commonplace, in order to expedite the writing process that staff use abbreviations to document the service provided. However, it is important to adhere to basic writing standards as well as the use of approved MCBH abbreviations contained within its list ensure clarity in documentation. Please ensure documentation is completed within the appropriate program under which you are providing the service. Generally, this means the program for which you, the practitioner, are assigned to in order to avoid issues with the submission of billing for services. Please note that County staff are not permitted to write process notes in a contracted Provider episode and vice-versa; contracted Provider staff are not permitted to write progress notes in a County episode. Doing so will have financial impact to the programs. In the rare event that you provided a brief service to an individual/family that was previously opened for services, but is no longer receiving services. Please review the Call Log section for information on how this service may be documented. FREQUENCY OF DOCUMENTATION OF SERVICES Progress notes shall be documented at the frequency by type of service indicated below: 1. Every Service/Contact (claiming by the minute) a. Mental Health Services b. Targeted Case Management c. Medical Support Services d. Crisis Intervention 2. Daily (claiming by the day) a. Crisis Residential b. Crisis Stabilization (1x/23hr period) c. Day Treatment Intensive 3. Weekly (claiming by the week) a. Day Rehabilitation b. Adult Residential c. Day Treatment Intensive: a clinical summary reviewed and signed by a physician, a licensed/ waivered/ registered psychologist, clinical social worker, or marriage and family therapist; or a registered nurse who is either staff to the day treatment intensive program or the person directing the service. 4. Other a. Psychiatric health facility services: notes on each shift b. As determined by the MHP for other services

49 49 TIMELINESS OF DOCUMENTATION OF SERVICES All client-related services must be entered and finalized in the client Electronic Medical Records (EMR) within 72- business hours from when the service was provided. Any other documents related to a client (i.e. CPS reports, labs, etc.) must also be entered/scanned in the client s clinical record within 72-business hours. The intent of the 72-hour documentation policy is to establish a trend of timely documentation. All Behavioral Health direct service staff is expected to enter and finalize progress notes, in the EMR, a minimum of 90% compliance with the 72-business hour documentation standard. State regulations drive timeliness standards, which are based on the idea that documentation completed in timely manner has greater accuracy and makes needed clinical information available for best care of the client. State guidelines and auditors practice established the 72-business hour documentation time frame utilized in Monterey County Behavioral Health. [1] However, perfection is not expected. QI recognizes that documentation cannot always be completed within 72-business hours. Situations may arise that prevent timely documentation, such as sickness, client crisis, or scheduling challenges. As with any trend s longevity, timely documentation is meant to be evaluated on a long-term basis. In cases where documentation is late, staff should document a brief reason for the late entry. The reason should be placed in the beginning of the progress note but should not be in extensive detail. For example, an entry such as Late entry due to other client crisis should suffice. There are often questions on how to the timeline expectation applies to services that occur at the end of the business day on Fridays or the day before a holiday. Progress notes need to be completed within 72-business hours from when the service was provided. The same rules apply for staff working alternative or modified schedules, the 72-hour business hours includes all regular hours of Behavioral Health operation (excluding weekends and holidays) even if it coincides with a regularly scheduled day off that fall on a Behavioral Health business day. For example, staff working four 10 hour days with Fridays off must take into account that their regularly scheduled Friday off is still part of the calculations for the 72- business hour documentation standards. There are some staffing classifications, such as new employees or interns, who require a reviewer or clinical supervisor to review the progress notes prior to finalization. Even in these instances, the 72-business hour standards apply. Generally, the practitioner completes a progress note, selects the co-signature option, and finalizes the progress note. This process sends the reviewer a to do message in their AVATAR inbox. The reviewer then reviews the progress note and provides the practitioner with feedback, if any. The use of supervision to provide feedback on progress notes is always encouraged, however, the feedback may be provided by or telephone. Depending on the feedback, the practitioner has the option to append the progress note to include any necessary information regarding the service provided. If the progress requires more than the use of the append option, please contact the QI HelpLine for support. APPEND PROGRESS NOTES The Append Progress Notes form in AVATAR may be used to include additional information to a progress note for added clarity, after the progress note has been finalized. The Append option does not permit changes to the original progress note. It simply appends or adds information to the progress note by including the new information to the end of the finalized progress note. [1] Policy 129 Medical Records Documentation

50 50 In addition, when there is an error in the content of the progress note, the progress note may be appended to reflect the accuracy of the services that were provided. For errors that are related to the accuracy for billing purposes, an error report must be submitted to make necessary corrections for the services billed. Note: The appended section of the progress note is not visible when viewing progress notes through the widget in chart overview. To view the progress note with the appended information, you must use a crystal report, such as Progress Notes Viewer, to view the full content of the progress note. Unfortunately, this is a functional issue within the EMR and cannot be modified. ALL ABOUT FIRP FIRP is an outline of what should be included in a progress note. The FIRP format represents Functioning, Intervention, Response, Plan (FIRP). Each section of FIRP should be identified by its corresponding label on the progress note. Functioning: This section should include the basics of who, where and what. Who was there? Where was the service provided (community, client s school By adding a second intervention and etc.)? What was the client s current behavior or functioning? It may be helpful then the client s response you can to include information about client s mental status in this section. We should concisely represent the service you begin to have an accurate picture of how the client is doing based on this provided. section. Remember, if it is not written it did not happen. You may be asked to describe the client s behaviors to others via reports at a later point. Was this a planned or unplanned service? Intervention: The intervention section of the note is critical. In this section of the progress note you state what you did to support the client s recovery and resiliency. The intervention should relate to one of the interventions listed in the treatment plan. Always document your INTERVENTIONS. This is how you show that you addressed the client s need within the standard of care. Include the PURPOSE of the intervention. For example, a safety plan to address client s hopelessness was developed to stabilize the crisis. Notes without an intervention represent a risk of audit disallowance. Basically we should not be asking the state to pay for a service if we cannot document what we did the intervention. The mental health intervention helps show why the service was medically necessary to address the mental health need. Response: The Response documents the CLIENT S reaction or reply to the mental health intervention you provided. Include information on why the intervention may not have been successful. You can include your clinical impression about the client s response. This is a great place to use quotes from the client, which can be very descriptive. Plan: This section addresses immediate needs, if any, that must be addressed either before or during the next session. This is a good way to communicate next steps to other providers involved in treatment. An example of necessary next steps may include an entry such as, will refer the client to a depression group to decrease isolative behaviors. You can Have a lot to say and feel like FIRP is holding you back? Try adding an extra I & R Documenting a Service with Two or More People Define the role of others Involved in the service - for example the client s mother participated in the session. When the service involves another client Do Not write a client s name in another client s chart. When the service involves a family member or support persons - If needed, you may use a first name or initials of another family member. Limit what you say about family members. It is not their chart. When the service involves two or more clients who are also family members - Write a note for each using the appropriate code.

51 51 also include actions the client will take before the next session. For example, client will use deep breathing exercise as a means to relax when feeling overwhelmed. Too often notes simply indicate more service, such as weekly group. A really good plan includes the why, not just the what. (e.g., Continue with weekly 1:1 meetings to reinforce use of XY coping skills ). Sometimes it s just FIP: With case management notes there may be times when there is no response to the intervention. In these situations we can omit the response R section of the note. This would mean a case management note such as coordination of referral for depression group would contain a FIP or Functioning, Intervention, and Plan. CONFIDENTIALITY IN PROGRESS NOTE CONTENT We must protect client confidentiality. The medical record is a legal document that may be subpoenaed by the court. Please observe the following standards in completing progress notes: Do not write another client s name (e.g., classmate, peer, etc.) in another client s chart. In the unusual circumstance when another client must be identified in the record (for example, when the other client received a Tarasoff warning), do not identify that individual as a behavioral health client, unless necessary. Names of family members/support persons should be recorded only when needed to complete intake registration and on financial documents. On progress notes and most assessments, refer to the relationship - mother, husband, friend, but do not use names. Use a first name or initials of another person only when needed for clarification. Be judicious in entering any mental health diagnosis reported by a parent/spouse/other about themselves or family members/support persons. (Indicate reported by... ). Certain Clinical progress notes may be designated restricted disclosure by individual providers and their supervisors/managers. Designating a clinical progress note as restricted disclosure alerts MCBH Quality Improvement staff to review the document and, if necessary, consult with the individual provider and/or their supervisor/manager prior to releasing the note as part of the client record request. (See Policy 129 Medical Records Documentation for more detailed information). Types of clinical progress notes that may be designated restricted disclosure include but are not limited to: Clinical Progress notes documenting fulfillment of a mandated reporting obligation (e.g., child abuse reporting, elder abuse reporting) as disclosure of this information may reasonably endanger the reporting provider. Clinical progress notes containing information that might reasonably endanger the life or physical safety of the client or another person. For minor clients, clinical progress notes containing information that would have a detrimental effect on the provider s professional relationship.

52 52 MENTAL HEALTH SERVICE CODES Mental Health Services are those individual, group, or family therapies and interventions that are designed to reduce mental disability. They also facilitate improvement or maintenance of functioning consistent with the goals of learning, development, independent living and enhanced self-sufficiency. Services are directed toward achieving the consumer/ family s goals and must be consistent with the current Client Treatment Plan. In this context, Mental Health Services is a term that includes the following services: Assessment Plan Development Mental Health Rehabilitation Therapy & Therapy Group Collateral Definitions for these and additional service codes are included below. You may also refer to the chart of allowable billing section of this document. INTENSIVE CARE COORDINATION (ICC) (201, 222, 208) Intensive Care Coordination (ICC) is similar to the activities that are routinely provided to our clients as Case Management. ICC must be delivered using a Child/Youth/Client and Family Team to develop and guide the planning and service delivery process. The difference between this service code and traditional Case Management is that ICC must be used to facilitate implementation of the cross-system/multi-agency collaborative services approach. ICC also differs from Case Management in that it typically requires more frequent and active participation by the ICC Coordinator to ensure that the needs of the child/youth are being met. The ICC Coordinator is the Care Coordinator assigned to the case. 201 Intensive Care Coordination (All other clients) 202 Intensive Care Coordination (IEP clients) 208 Intensive Care Coordination (Katie A.) Note: Billing Lockout rules apply. INTENSIVE HOME BASED SERVICES (IHBS) (221, 222, 228) Intensive Home Based Services (IHBS) are intensive, individualized and strength-based, needs-driven intervention activities that support the engagement and participation of the Child/Youth/Client and their significant support persons to help the child/youth develop skills to achieve the goals and objective of the plan. These are not traditional therapeutic services. This service differs from rehabilitation services in that it is expected to be of significant intensity to address the intensive mental health needs of the child/youth and are predominantly delivered outside of the office setting such as at the client s home, school or another community location. 221 Intensive Home Based Services (All other clients) 222 Intensive Home Based Services (IEP clients) 228 Intensive Home Based Services (Katie A.)

53 53 CRISIS INTERVENTION (271 & 272) Crisis Intervention is provided when the client requires an unplanned, immediate response or intervention that is intended to help a client exhibiting acute psychiatric symptoms which, if untreated, present an imminent threat to the client or others and help him/her stabilize and maintain in a community setting. The crisis must be a crisis related to the client. If a significant support person, such as a parent, is experiencing a crisis, the crisis code cannot be used; the client specifically must be in crisis 25 Examples of Crisis Intervention include services to clients experiencing acute psychological distress, acute suicidal ideation, or inability to care for themselves (including provision/utilization of food, clothing and shelter) due to a mental disorder. Service activities may include, but are not limited to assessment, collateral and therapy to address the immediate crisis. Crisis Intervention activities are usually face-to-face or by telephone with the client or significant support persons and may be provided in the office or in the community. 26 The maximum amount of time that can be spent on crisis intervention for a client in one day is 8 hours or 480 minutes. If a client is hospitalized, this code can only be used on the date of admission of an inpatient hospitalization Crisis Intervention (open outpatient episode) 272 Crisis Intervention (IEP Clients only) Crisis Assessment Progress Notes Describe: The immediate emergency requiring crisis response Interventions utilized to stabilize the crisis The client s response and the outcomes Detailed Safety Plan Follow-up plan and recommendations EXAMPLES OF CRISIS INTERVENTION ACTIVITIES: Client in crisis - assessed mental status and current needs related to immediate crisis. Danger to self and others assessed/provided immediate therapeutic responses to stabilize crisis. Gravely disabled client/current danger to self provided therapeutic responses to stabilize crisis. Client was an imminent danger to self/others - was having a severe reaction to current stressors. Note: Crisis Intervention progress notes may not always link to the client s treatment plan. 25 CCR, Title 9, Chapter 11, Section Welfare and Institutions Code. Reference: Section CCR, Title 9, Section &

54 54 CASE MANAGEMENT (301) Case management (302) used by School Based Teams Only Case Management (CM) are services that assist a client to access needed medical, educational, social, pre-vocational, vocational, rehabilitative, or other community services that are impacted by client s mental health. The service activities may include, but are not limited to, communication, coordination, and referral; monitoring service delivery to ensure client access to service; monitoring of the client s progress once he/she receives access to services; and development of the plan for accessing services. Interventions must clearly document the connection between the case management need and mental health needs. When CM services will be provided to support a client to reach mental health treatment goals, it must be listed as an intervention on the client treatment plan. Think about how the client s mental health is negatively impacting his/her ability to access these services or perform these activities without intervention by a mental health practitioner. Case management includes, but not limited to, the following: Inter-and intra-agency communication, coordination and referral. Monitoring service delivery to ensure an individual s access to service and the service delivery system. Linkage services focused on acquiring transportation, housing, or securing financial needs. Case management services also include placement service such as: Locating and securing an appropriate living environment. Locating and securing funding. Pre-placement visit(s). Negotiation of housing or placement contracts. Placement and placement follow-up. Accessing services necessary to secure placement. There are limitations to when case management can be provided. Institutional reimbursement limitations apply when case management is billable for clients in acute settings like the hospital (e.g. NMC). For clients in these facilities, case management services are billable only for the following purpose: Services must directly be related to discharge planning for the purpose of coordinating placement of the client upon discharge. This should be well documented in the progress note. If these criteria are not met, please document your services using the lockout service codes, as applicable. No other services may be claimed for clients in an acute psychiatric facility. The location code for these services is always the client s location, e.g., acute psychiatric hospital. As is the case with all mental health services, clients cannot be compelled to receive case management services. 28 Clients must consent to receive the services and may not be denied other services on the condition of receipt of case management services. Note: Case Management services are not reimbursable on days when a client is receiving Psychiatric Inpatient Hospital Services, Psychiatric Health Facility Services or Psychiatric Nursing Facility Services are reimbursed, except for the day of admission to these services or for the purpose of coordinating placement of the client upon discharge CFR (A)(2) 29 State Plan Amendment #10-012B Targeted Case Management

55 55 COLLATERAL (311) Collateral (312) used by School Based Teams Only This code is used to document contact with any Significant Support Person in the life of the client (e.g., family members, roommates) with the intent of improving or maintaining the mental health of the client. This excludes other professionals involved in the client s care. Collateral may include helping significant support persons understand and accept the client s challenges/barriers and involving them in planning and provision of care. Remember, there must be a current Authorization to Use, Exchange, or Disclose Confidential Information in the chart to include these supports in treatment. These services must be included in the client s treatment plan to support the client s recovery. Collateral may include, but is not limited to: The client may or may not be present. 30 Consultation and training of the significant support person to assist in better utilization of mental health services by the client. Consultation and training of the significant support person to assist in better understanding of the client s serious emotional disturbance (e.g., psychoeducation). Note: When consulting with other professionals involved with care use the case management service code. Collateral Progress Notes Describe: List people involved in the services and their role Training/Counseling provided to the Significant Support Person Describe how the client's mental health goals were addressed through the collateral support. Document the collateral support person s response to the mental health 30 Section Collateral

56 56 NON-BILLABLE SERVICES (330) This code is used to document services that were delivered, but do not meet medical criteria for service delivery. This code along with the No Medical Necessity codes are used to document services that are relevant to the client s care, but are not Medi-Cal reimbursable. This 330 service code must be used in the event the record is out-of-compliance in accordance of documentation standards. This 330 code and no medical necessity codes may be used by any practitioner. The following services are not Medi-Cal reimbursable: 1. Any documentation after the client is deceased. 2. Preparing documents for court testimony for the purpose of fulfilling a requirement. Whereas when the preparation of documents is directly related and reflects how the intervention impacts the client s mental health treatment and/or progress in treatment, then the service may be billable. 3. Completing the reports for mandated reporting such as a CPS or APS. 4. No service provided: Missed visit. Waiting for a no show or documenting that a client missed an appointment. 5. Services under 5 minutes. 6. Traveling to a site when no service is provided due to a no show. Leaving a note on the door of a client or leaving a message on an answering machine or with another individual about the missed visit. 7. Personal care services provided to individuals including grooming, personal hygiene, assisting with selfadministration of medication, and the preparation of meals. 8. Purely clerical activities (faxing, copying, calling to reschedule, appointment, etc.) 9. Recreation or general play. 10. Socialization-generalized social activities which do not provide individualized feedback. 11. Childcare/babysitting. 12. Academic/Educational services- actually teaching math or reading, etc. 13. Vocational services which have, as a purpose, actual work or work training. 14. Multiple Practitioners in a Case Conference or meeting: Only practitioners directly contributing (involved) in the client s care may claim for their services. Each practitioner s unique contribution in the meeting must be clearly noted. 15. Supervision of clinical staff or trainees is not reimbursable because it does not center around client care (i.e. development of personal insight that may be impacting clinician s work with the client). Whereas, reviewing and amending/updating the treatment plan with a supervisor is reimbursable (i.e. the topic of discussion is centered on exploring alternative interventions that may be helpful in helping client reach his/her goals). 16. Utilization management, peer review, or other quality improvement activities that have already been billed to the client. (In order to avoid double billing, if the utilization management has been billed to the client, then do not document this time as QI time). 17. Interpretation/Translation ONLY: an intervention must be provided to client in order to make service billable. 18. Lock-Out setting for things not covered in lock-out codes (refer to chart of allowable billing ). 19. Providing transportation. Clarification on above items: As long as the focus of the service meets medical necessity criteria, the following are examples of reimbursable services. Academic/Educational Situations: Reimbursable: Sitting with the consumer in a community college class to help reduce the consumer s anxiety and then debriefing the experience afterward. Not Reimbursable: Assisting the consumer with his/her homework. Not Reimbursable: Teaching a typing class at an adult residential treatment program. Recreational Situations: Reimbursable: Introducing a consumer to a Wellness Center and debriefing his/her visits. Not Reimbursable: Teaching the individual how to lift weights. Vocational Situations: Reimbursable: Responding to the employer s call for assistance when the client is in tears at work because he/she is having trouble learning to use a new cash register-- if the focus of the intervention is assisting the individual to decrease his anxiety enough to concentrate on the task of learning the new skill. Not Reimbursable: Visiting the consumer s job site to teach him/her how to use a cash register.

57 57 NO MEDICAL NECESSITY CODES (NO MN) These No Medical Necessity codes (see below) can be used when services must be provided but the client does not meet Medical Necessity as defined by Medi-Cal. These codes may be used by any practitioner. These codes function the same as the 330 service code, however, they more accurately document the type of service delivered. Oftentimes, these codes are used by those MCBH programs that work in partnership with other providers and agencies that fund services and decide the frequency of services, etc. It may occur that Medi-Cal s definition of medical necessity is not met, but the partner program wishes for us to continue to provide services to the client. For example, clients with an IEP whose services are the responsibility of the school district, not Medi-Cal, may use these codes. Other times, programs use these codes to clearly delineate the no medical necessity services provided by their program. For example, this code may be used when documenting transportation without a mental health intervention or rescheduling an appointment for the client. These No Medical Necessity codes use the exact criteria as the MCBH outpatient service code (i.e. Collateral, Case Management, the use of FIRP etc.) The same rules apply with regards to scope of practice and practitioners may bill accordingly. These codes simply note that there is no Medi-Cal medical necessity criteria met. Please refer to Lock-Out service codes for documenting services provided while the individual is in a lock-out setting. IEP Clients All Other Clients 305 No MN Case Management 401 No MN Case Management 315 No MN Collateral 411 No MN Collateral 335 No MN Assessment 431 No MN Assessment 345 No MN Individual Therapy 441 No MN Individual Therapy 355 No MN Group 451 No MN Group 385 No MN Mental Health Rehabilitation 481 No MN Mental Health Rehabilitation 395 No MN Plan Development 491 No MN Plan Development Note: When searching these codes by name in the EMR, please use No MN to populate the results.

58 58 ASSESSMENT (331) Assessment (332) used by School Based Teams Only This code is used to document the clinical analysis of the history and current status of the individual s mental, emotional, or behavioral condition. It includes appraisal of the individual s functioning in the community such as living situation, daily activities, social support systems, and health history and status. Assessment includes screening for substance use/abuse, establishing diagnoses and may include the use of testing procedures. Assessment services must be provided by a licensed and/or licensed waived practitioner consistent with his/her scope of practice. Assessment services may include: Gathering information to gain a complete clinical picture. Completing an admission assessment and annual re-assessment. All mental health services provided to assess a child/youth for eligibility for mental health treatment through an IEP process should be coded as assessment. Assessment Progress Notes Describe: People involved in the services and their role. Clear description of why assessment is being completed and/or the reasons for referral for assessment. Clinician s interventions, including observations of the client during the session. Client responses to interventions. Describes preliminary findings and your clinical hunches. Information on the follow up plan or next steps. If medical necessity is met, clearly document how it is met. TRIAGE (336) ACCESS TO TREATMENT TEAMS ONLY Triage code may be used by Access to Treatment programs when triage procedures are used for determination of the individual s needs. This code is used to document services that were delivered, but do not meet medical criteria for service delivery. This code is used to document services that are relevant to the client s care, but are not Medi-Cal reimbursable. Note: Please refer to your supervisor/manager regarding workflows and the use of this code

59 59 INDIVIDUAL THERAPY ( 341) Individual Therapy (342) used by School Based Teams Only "Therapy" means a service activity that is a therapeutic intervention that focuses primarily on symptom reduction of functional impairments and restoration of functioning as a means to improve coping and adaptation. Therapeutic intervention includes the application of strategies incorporating the principles of development, wellness, adjustment to impairment, and recovery and resiliency. Therapy should assist a client in acquiring greater personal, interpersonal and community functioning or to modify feelings, thought processes, conditions, attitudes or behaviors. These interventions and techniques are specifically implemented in the context of a professional clinical relationship. Therapy may be delivered to a client or group of beneficiaries and may include family therapy directed at improving the client's functioning and at which the client is present. 31 Note: Only licensed and/or licensed waived practitioners, who have the training and experience necessary to provide therapy, can bill for this code. MENTAL HEALTH GROUP REHABILITATION (351) This code is based on the specific service being provided and is used for rehabilitation interventions offered to more than one client in a group setting. Mental Health Rehabilitation Services may be provided to more than one individual at the same time. One or more practitioners may provide these services and the total time for intervention and documentation may be claimed (up to 3 practitioners may be claimed). A varying amount of time may be claimed for each practitioner. This code is used to document assisting clients, in a group setting in improving skills or the development of a new skills. Rehabilitation" means a recovery or resiliency-focused service activity identified to address a mental health need in the client plan. This service activity provides assistance in No need to do math! The EMR will do it for you: Example: A group service is provided by two practitioners for a group of seven clients, and the reimbursable service, including direct service, travel time, and documentation. All this took 1 hour and 35 minutes (95 minutes). The total units reported will be divided between the two practitioners members divided by the number of clients. The EMR system will provide the allocation of time for each client present; round to the nearest minute. restoring, improving, and/or preserving a client s functional, social, communication, or daily living skills to enhance selfsufficiency or self-regulation in multiple life domains relevant to the developmental age and needs of the client. Rehabilitation also includes support resources, and/or medication education (within the practitioner s scope of practice). This code may be claimed by any practitioner. Group Rehabilitation services are provided as part of a comprehensive specialty mental health services program available to Medicaid (Medi-Cal) clients that meet medical necessity criteria established by the State. They are based on the client s need for Rehabilitative Mental Health Services established by an assessment and documented in the client plan. Rehabilitative skills may include: Daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication compliance. Counseling of the consumer including psychosocial education aimed at helping achieve the individual s goals. Education around medication, such as understanding benefits of medication (within the practitioner s scope). 31 State Plan Amendment # Rehabilitative Mental Health Services

60 60 Only one group progress note is written for each client even if 2 or 3 practitioners lead the group. One practitioner writes and signs/finalizes the progress notes. A good group note includes specific interventions and specific responses/observations for each client in the group setting. Note: Please refer to the EMR User Guide for step-by-step instructions and instructional video on the technical aspects of writing group notes. MENTAL HEALTH GROUP THERAPY (353) Psychotherapy means the use of psychological methods within a professional relationship to assist the beneficiary or beneficiaries to achieve a better psychosocial adaptation, to acquire a greater human realization of psychosocial potential and adaptation, to modify internal and external conditions that affect individual, groups, or communities in respect to behavior, emotions and thinking, in respect to their intrapersonal and interpersonal processes. 32 This code is based on the specific service being provided and is used for psychotherapy interventions offered to more than one client in a group setting. Psychotherapy services may be provided to more than one individual at the same time. One or more practitioners may provide these services and the total time for intervention and documentation may be claimed (up to 3 practitioners may be claimed). This code may be claimed by practitioners who are licensed, registered, or waivered practicing within their scope of practice. A varying amount of time may be claimed for each practitioner. Only one group progress note is written for each client even if 2 or 3 practitioners lead the group. One practitioner writes and signs/finalizes the progress notes. A good group note includes specific interventions and specific responses/observations for each client in the group. Note: Only licensed and/or licensed waived practitioners, who have the training and experience necessary to provide therapy, can bill for this code. Please refer to the EMR User Guide for step-by-step instructions and instructional video on the technical aspects of writing group notes. FAMILY GROUP COUNSELING (356) We recognize that there may be times when we may provide services to multiple family members opened to mental health services. This code is used to document the services provided to family members where more than one family member is opened to services and were present during a particular service. The aim is that this code will help to ensure that all clients, who were present during the service, receive appropriate documentation in their medical record. A good family group counseling progress note will clearly indicate the reason for the service, the specific interventions used, and the individual s response to the interventions. The progress note should directly link back to a goal in the client s treatment plan. Note: This progress note requires the use of group progress notes. Please refer to the EMR User Guide for step-by-step instructions and instructional video on the technical aspects of writing group notes. 32 Mental Health Plan Contract

61 61 FAMILY THERAPY (357) There are many times when family therapy is warranted in treatment in order to assist the client in their recovery. This code is used to document services provided to a client and one or more family members which focus on symptom reduction as a means to improve functional impairments. This is different than the 356 service code because the family members are NOT opened to mental health services within our system. Licensed/Registered/Waivered Staff and trainees can utilize this code provided that they are working within their scope of practice. COLLATERAL GROUP COUNSELING (358) This code is for group services that are provided to a client s family for the purpose of psychoeducation, support, etc., as it relates to the client s mental health needs. This code is specifically helpful to accurately document the services provided to the client s family that may be helpful in gaining a better understanding of the client s mental health needs or of mental health in general. Note: This service requires the use of group progress notes. CRISIS TEAM ONLY-- CRISIS INTERVENTION (371) This service code is used exclusively by the crisis team members to document any services provided to client opened to services within our system. The use of this service code is important because it allows for communication and good clinical care to accurately reflect services provided to clients. Provided counseling to the client's significant support person(s) involved in crisis stabilization - how to follow the safety plan. A Crisis Intervention progress note documents a service to address an immediate mental health emergency and describe the nature of the crisis, the crisis stabilization interventions utilized, the client s response and the overall outcome

62 62 MENTAL HEALTH REHABILITATION (381) Mental Health Rehabilitation (382) used by School Based Teams Only This code is used to document assisting the client in improving a skill or the development of a new skill set. Rehabilitation" means a recovery or resiliency-focused service activity identified to address a mental health need in the client plan. This service activity provides assistance in restoring, improving, and/or preserving a client s functional, social, communication, or daily living skills to enhance self-sufficiency or self-regulation in multiple life domains relevant to the developmental age and needs of the client. Rehabilitation also includes support resources, and/or medication education (within the practitioner s scope of practice). This code may be claimed by any practitioner. Rehabilitative Mental Health Services are provided as part of a comprehensive specialty mental health services program available to Medicaid (Medi-Cal) clients that meet medical necessity criteria established by the State. They are based on the client s need for Rehabilitative Mental Health Services established by an assessment and documented in the client plan. Rehabilitative skills may include: Daily living skills, social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and/or medication compliance. Counseling of the consumer including psychosocial education aimed at helping achieve the individual s goals. Education around medication, such as understanding benefits of medication (within the practitioner s scope). PLAN DEVELOPMENT (391) Plan Development (392) used by School Based Teams Only This code is used to document the development of the client s treatment plan, review the treatment plan with the client or treatment team, and/or monitor the client s progress related to the client treatment plan. Plan Development may be claimed by any practitioner. Plan Development is expected to be provided during the development of the initial treatment plan and for subsequent treatment updates. However, it may be used during other times, as clinically indicated to address the client s needs. For example, when the client s status changes (i.e., significant improvement or deterioration) and there may be a need to update the treatment plan. Plan development includes: Monitoring progress to evaluate if the client care plan needs modification. Consultation/collaboration with mental health practitioners or other professionals to evaluate the treatment plan (e.g. probation officer, teachers, and social workers) involved in the client s care to develop, approve, or to modify the client care plan. 33 Note: Time spent developing acute care discharge plans may be claimed as Case Management (301). The Utilization Review process should be coded using the Utilization Review/Quality Improvement (UR/QI) indirect service code (802). Any recommendations by the reviewer must be completed by the practitioner and may not be billed to the client nor should the non-billable service code or any other service code be used to document the time spent on these corrections. 33 State Plan Amendment # Rehabilitative Mental Health Services

63 63 LOCKOUT CODES: CASE MANAGEMENT (405), COLLATERAL (475) & MENTAL HEALTH (485) These codes are used to accurately reflect the services provided to those individuals who are in setting that are considered Lockout settings. You may use these codes when providing case management services, collateral services, or mental health services. Lock out settings may include: incarcerated, inpatient unit, medical hospital, adult day treatment, crisis residential, IMD, etc. These codes may be used when services that may benefit the client s recovery are provided while the individual is in what is considered a lock-out setting. Please refer to the chart of allowable billing for more billing code information. MENTAL HEALTH SERVICE CODES FOR MEDICAL TEAM MEDICATION SUPPORT SERVICES (361) This code is used exclusively by medical staff when it is within their scope of practice to provide these services. This service code may include: providing detailed information about how medications work; different types of medications available and why they are used; anticipated outcomes of taking a medication; the importance of continuing to take a medication even if the symptoms improve or disappear (as determined clinically appropriate); how the use of the medication may improve the effectiveness of other services a client is receiving (e.g., group or individual therapy); possible side effects of medications and how to manage them; information about medication interactions or possible complications related to using medications with alcohol or other medications or substances; and the impact of choosing to not take medications. Medication Support Services supports beneficiaries in taking an active role in making choices about their mental health care and helps them make specific, deliberate, and informed decisions about their treatment options and mental health care. Note: Medication support services may only be provided within their scope of practice by a Physician, a Registered Nurse, a Certified Nurse Specialist, a Licensed Vocational Nurse, a Psychiatric Technician, a Physician Assistant, a Nurse Practitioner, and a Pharmacist. Limitations: The maximum number of hours claimable for medication support services in a 24-hour period is 4 hours. This service is not duplicative of the drug counseling requirements described in 42 CFR

64 64 MEDICATION SUPPORT SERVICES-- TELEPSYCHIATRY (361-T) This code is used exclusively by medical staff who provide services via telepsychiatry within their scope of practice. This service code may include: providing detailed information about how medications work; different types of medications available and why they are used; anticipated outcomes of taking a medication; the importance of continuing to take a medication even if the symptoms improve or disappear (as determined clinically appropriate); how the use of the medication may improve the effectiveness of other services a client is receiving (e.g., group or individual therapy); possible side effects of medications and how to manage them; information about medication interactions or possible complications related to using medications with alcohol or other medications or substances; and the impact of choosing to not take medications. Medication Support Services supports beneficiaries in taking an active role in making choices about their mental health care and helps them make specific, deliberate, and informed decisions about their treatment options and mental health care. Note: Medication support services may only be provided within their scope of practice by a Physician, a Registered Nurse, a Certified Nurse Specialist, a Licensed Vocational Nurse, a Psychiatric Technician, a Physician Assistant, a Nurse Practitioner, and a Pharmacist. Limitations: The maximum number of hours claimable for medication support services in a 24-hour period is 4 hours. This service is not duplicative of the drug counseling requirements described in 42 CFR MEDICATION SUPPORT SERVICES FOR URGENT APPOINTMENT (361-U) This code is used exclusively by medical staff within their scope of practice. This code may be used to provide urgent medication support services to an individual. Urgent is defined by the client at the time of requesting the appointment or by the practitioner requesting the urgent appointment in an effort to avoid further decompensation by the client. The individual may or may be new to services within MCBH. This service code may include: providing detailed information about how medications work; different types of medications available and why they are used; anticipated outcomes of taking a medication; the importance of continuing to take a medication even if the symptoms improve or disappear (as determined clinically appropriate); how the use of the medication may improve the effectiveness of other services a client is receiving (e.g., group or individual therapy); possible side effects of medications and how to manage them; information about medication interactions or possible complications related to using medications with alcohol or other medications or substances; and the impact of choosing to not take medications. Medication Support Services supports beneficiaries in taking an active role in making choices about their mental health care and helps them make specific, deliberate, and informed decisions about their treatment options and mental health care. Note: Medication support services may only be provided within their scope of practice by a Physician, a Registered Nurse, a Certified Nurse Specialist, a Licensed Vocational Nurse, a Psychiatric Technician, a Physician Assistant, a Nurse Practitioner, and a Pharmacist. Limitations: The maximum number of hours claimable for medication support services in a 24-hour period is 4 hours. This service is not duplicative of the drug counseling requirements described in 42 CFR

65 65 MEDICATION SUPPORT SERVICES LOCK OUT SETTING (364) This code is used exclusively by medical staff when it is within their scope of practice to provide these services. This code is used to accurately reflect services provided to those individuals who are in setting that are considered Lockout settings. Lock out settings may include: incarcerated, inpatient unit, medical hospital, adult day treatment, crisis residential, IMD, etc. Please refer to the chart of allowable billing for more billing code information.

66 66 ASSESSMENT/REASSESSMENT/TREATMENT PLANNING 1. A diagnosis (DSM-5 and ICD-10) must be completed prior to claiming any service 2. During the assessment, renewal and treatment planning timeframes, staff may only use specific designated codes. Service Code Permitted during Diagnosis, Assessment, Renewal, and Treatment Planning Process? 201, 202, Intensive Care Coordination NO 221, 222, Intensive Home Based NO 271, Crisis Intervention (Outpatient/IEP Clients only) YES Case Management* *YES, but with limited time on 302 Case Management (School Based Teams Only)* outreach and linkage only 311 Collateral 312 Collateral (School Based Teams Only) NO Non-Billable YES 331 Assessment YES 332 Assessment (School Based Teams Only) 336 Triage (ACCESS to Treatment teams only) YES Individual Therapy 342 Individual Therapy (School Based Teams Only) 351, 353, 356, 357, 358 Group Rehabilitation, Group Therapy, Family Group NO Counseling, Family Therapy, Collateral Group Counseling Crisis Intervention (Crisis team only) YES Mental Health Rehabilitation 382 Mental Health Rehabilitation (School Based Teams Only) Plan Development YES 392 Plan Development (School Based Teams Only) 405, 475, Lockout YES 305, 315, 335, 345, 355, 385, 395 No Medical Necessity for IEP School Based Teams Only 401, 411, 431, 441, 451, 481, 491 No Medical Necessity for all other clients Medical Team Specific Codes Medication Support NO 361U Medication Support for Urgent Appointment Medication Support in Lockout setting YES 331T Telemedicine - Assessment 341T Telemedicine - Therapy 361T Telemedicine Medication Support * Limited case management services is defined as short period of time where case management services are used to support client engagement, outreach, and linkage to other community resources. Limited refers to a short period of time and targeted support. NO NO YES YES YES NO NO NO

67 67 3. Once the diagnosis, assessment, reassessment, and treatment plan have been completed and finalized, staff may utilize other available service codes. Documentation standards for service codes as noted in the Monterey County Behavioral Health Documentation Guide and policies and procedures must be followed. LINKING SERVICES TO THE TREATMENT PLAN ALL service codes with the exception of Non-Billable services and Crisis Intervention service codes, MUST link to the client s treatment plan goals with the following exceptions: Please note: For all clients, a treatment plan must be completed in order to link to the service. Service Code Linked to Treatment Plan 201, 202, Intensive Care Coordination Yes 221, 222, Intensive Home Based Yes 271, Crisis Intervention (Outpatient/IEP Clients only) No Case Management 302 Case Management (School Based Teams Only) 311 Collateral Yes Non-Billable No 331 Assessment Assessment (School Based Teams Only) 331T Assessment for Telemedicine 336 Triage (Access to Treatment Programs Only) No Individual Therapy 342 Individual Therapy (School Based Teams Only) 341T Individual Therapy for Telemedicine 351, 353, 356, 357, 358 Group Rehabilitation, Group Therapy, Family Group Counseling, Family Therapy, Collateral Group Counseling Medication Support Yes 361U Medication Support for Urgent Appointment 361T Medication Support for Telepsychiatry Medication Support in Lockout setting Yes Crisis Intervention (Crisis team only) No Mental Health Rehabilitation 382 Mental Health Rehabilitation (School Based Teams Only) Plan Development 392 Plan Development (School Based Teams Only) 405, 475, Lockout Yes 305, 315, 335, 345, 355, 385, 395 No Medical Necessity for IEP clients Yes 401, 411, 431, 441, 451, 481, 491 No Medical Necessity for all other clients Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

68 68 CHART OF ALLOWABLE BILLING Mental Health Services (221, 222, 228, 311, 331/332, 341/342, 351, 353, 356, 357, 358, 381/382, 391/392, 331T, 341T) Med Support (361, 361-T, 361-U) Case Management (201, 202, 208, 301/302) Crisis Intervention (271, 272, *371) Hospital Inpatient Hospital Inpatient Admin Day Day Treatment Adult Crisis Residential MH/TBS M M M M A L L A Med Support M M M M A L M M Case Management Day Treatment 34 Crisis Intervention 35 Hospital Inpatient M M M M I I M M T M M M A L L A M M M M A L M A A A I A L L A A Hospital L L I L L L L L Inpatient Admin Day Adult Crisis A M M A A L A L Residential Jail L L L L L L L L *371 service code to be used ONLY by Crisis Team clinicians Code Color What it means I = Institution Limitations This code indicates that only services geared towards discharge L= Lockout* Do not bill A= Lockout except for day of admission T= lockout during actual time service is provided M=Multiple Services on same day planning are permitted. Only bill this code on the admission date Do not provide this service at the same time as a specified service. For example, we cannot bill for both a mental health service and day treatment at the same time You can enter services, but be mindful of daily maximum. *Please refer to the description for Lockout service codes that may be used for services provided in lockout settings. 34 Limitations: Mental health services are not reimbursable when provided by day treatment intensive or day rehabilitation staff during the same time period that day treatment intensive or day rehabilitation services are being provided. Authorization is required for mental health services if these services are provided on the same day that day treatment intensive or day rehabilitation services are provided. State Plan Amendment # Rehabilitative Mental Health Services 35 Limitations: Crisis intervention is not reimbursable on days when crisis residential treatment services, psychiatric health facility services, or psychiatric inpatient hospital services are reimbursed, except for the day of admission to those services. The maximum amount claimable for crisis intervention in a 24 hour period is 8 hours. State Plan Amendment # Rehabilitative Mental Health Services

69 69 CHART OF BILLING DAILY MAXIMUM PER CLIENT Short Title Long Title Service Codes Max billing PER Client MH/TBS Services Mental Health or Therapeutic Behavioral Services 221, 222, Intensive Home Based Services Collateral 331/332 - Assessment 341/342 - Individual Therapy Group Rehabilitation Group Therapy Family Group Counseling 357- Family Therapy 358- Collateral Group Counseling 381/382 - Mental Health Rehab 391/392 - Plan Development 331T Telemedicine Assessment 341T Telemedicine Therapy Med Support Medication Support 361- Medication Support 361U Medication Support Urgent 361T Medication Support Telepsychiatry Case Management Crisis Intervention Case Management 201, 202, Intensive Care Coordination (ICC) 301/302 - Case Management Max of 2,878 minutes per day Max 4 hours or 240 minutes per day per Maximum of 24 hours (1440) minutes per day Crisis Intervention 271, 272, Crisis Intervention 8 hours (480 minutes) per day SERVICE CODE COMPARISON At times it can be difficult to distinguish between case management services and mental health services. A common misconception is that if the service is on a treatment plan then it is a mental health service. This is not accurate. Services that support the client to improve skills are considered Mental Health services, where Case Management services involve the staff completing activities to support the client. Here are a few examples. Need Client wants a job Rep-payee or Budget problems School Problems Risk of losing placement Access to treatment client needs help applying for medical Case Management Service (i.e. 201, 222, 208) Staff reviews record and completes referral to employment services. Making a referral to budget group and coordinating with another provider regarding client s budget needs. Consulting with education staff regarding clients school behavior Consulting with care providers regarding client s changing needs Filling out paperwork for the client or consulting with DSES on behalf of the client. Note: NEVER bill for clerical activities; this is not a billable service. Mental Health Services (i.e. 381, 341, 311, 221, 222, 228) Staff works with client to try coping skills to manage anxiety when client Providing interventions such as helping the client to develop a realistic budget and identifying past barriers to maintaining budget. Working with client and parent to practice behavioral interventions that help client to complete assigned homework. Meeting with client to discuss triggers to acting out behaviors. Working with client to identify how anxiety impacts ability to apply for medical.

70 70 FINALIZING A NOTE When a practitioner finalizes the progress note they are providing a legal electronic signature that the information they are submitting is accurate. Finalizing a progress note generates a billing for the services provided to the client. In the event of a progress note was completed in error, complete the Error Reporting form as soon as possible to identify the service needing correction. CLINICAL SUPERVISION AND BILLING It is important to remember that the Board of Behavioral Sciences and Board of Psychiatry do not govern Department of Health Care Services (DHCS) billing. Clinical supervision is billable as consultation using the Case Management 301 service code or the Plan Development 391 service code when: Discussing a client s case for the purposes of consultation toward meeting treatment plan goals (301). Consultation/collaboration with mental health practitioners or other professionals (e.g. probation officer, teachers, and social workers) is to evaluate the treatment plan, approve, or to modify the client care plan (391). The supervision is centered around identification of treatment strategies that may benefit the client, thus documentation of this in the plan section of the FIRP note (301). Consultation that is geared at determining appropriate diagnosis given client presentation (301). NOT billable: When discussing a new technique or approach to use with a client and the discussion focuses on learning for the practitioner. Transference or counter-transference issues. Personal items that are impacting the clinical treatment. Organizational/staffing issues that are impacting the clinical treatment. Some program discussions that occur within supervision may be billable as Quality Improvement time, specifically as it relates to the education or technical aspects of these procedures: Treatment Plans Progress note format and documentation Medical Necessity procedures Mental Status procedures Psychosocial Assessment content and procedures

71 71 INDIRECT SERVICE CODES These codes are used to document all indirect service codes in the Scheduling Calendar option of the EMR. These codes are necessary to accurately reflect the practitioner s services that are not a part of the direct services. The accuracy of the information entered in the Scheduling Calendar is important because it informs the productivity report. 801=Staff Meeting: This code is used for meetings such as the all-staff system of care meetings or other non-quality Improvement meetings. Which indirect service codes factor into the 75 % productivity report? Service Code 801=Staff Meeting Part of 75% No 802=Utilization Review/Quality Improvement (UR/QI): Please see policy 454 for detail, in general, Team meetings conducting UR, Quality Improvement Trainings, and Quality Improvement Committee meetings are all part of the UR/QI time. The activities considered appropriate to code as Quality Improvement time are listed below: 1. Utilization review and training activities related to monitoring of mental health plan program integrity standards, including services provided by subcontractors; 2. Utilization review and training activities required as part of clinical performance improvement projects (e.g. utilization committee) 3. Quality Improvement (QI) Committee meetings, preparation time, documentation of minutes, and follow-up of clinical QI issues; 4. Clerical time spent supporting utilization review chart selection, gathering of chart and billing documentation, and follow-up of clinical QA issues; QA activities required for development, implementation, evaluation, and revision of clinical practice guidelines; 5. Utilization review activities required for Therapeutic Behavioral Services (TBS), assistance with state audits, and federal audits of TBS; 6. Personnel time and materials for assisting state and federal auditors with county audits for compliance with External Quality Review standards, and other related Medi-Cal specialty mental health services standards; 7. Utilization review activities required as part of medication monitoring; 8. Training of SPMP (Skilled Professional Medical Provider) and staff who are directly supporting SPMP for utilization review and QA activities; 9. Personnel time required for the operation of management information systems that are necessary for completion of utilization review activities =Utilization Review/QI 803=Vacation/Sick 805=Indirect Services 806=Training 807=Supervision 808=Committee work 809=Non-Working Time 811=Outreach and Engagement 812=Early Intervention 813=Indicated/Selected (Prevention) 814=Universal (Prevention) 815=Critical Incident Debriefing Yes Yes No No No No Yes Yes Yes Yes Yes Yes 816=Hostage Negotiation Yes 817=Community Training Yes 36 Behavioral Health Policy =Access Program Clinician of the Day No

72 72 803=Vacation/Education Leave/Sick: This code is used to reflect time when a staff member was on vacation, used educational leave, or was out sick. This time should match the time entered on your timecard. 805=Indirect Services: This service code is used for services that are not client specific or should not be entered in the medical record. Examples include; staff who take vehicles to maintenance or some payeeship activities. Please enter details of these services in the notes tab of this form. 806=Training: This category is used to record trainings that are not part of Quality Improvement. Please enter details of these services in the notes tab of this form. 807=Supervision: This service code is used for supervision received by practitioner that is not billed to a client s chart. 808=Committee Work: This service code is used for committee work that staff participates in that is not otherwise accounted for as a Quality Improvement Committee. Please enter details of these services in the notes tab of this form which gives specific details on the committee name and function. 809=Non-Working Time/Jury Duty: This service code is used for staff with an adjusted work schedule. For example, if a staff member works 32 hours a week, then 8 hours should be entered in scheduling calendar as non-working time so productivity can be accurate calculated. 819=Access Team-Officer of the Day: this is used exclusively by the Access to Treatment program to block time on the calendar for assessment purposes. For Programs allocated MHSA funding, the following service codes are available: 811=Outreach and Engagement: This funding was established in recognition of the special activities needed to reach underserved populations. Outreach and engagement can be one component of an overall approach to reducing ethnic disparities. 812=Early Intervention: This code is used for early intervention activities designed to provide interventions to individuals before they enter services. 813=Indicated/Selected (Prevention) 814=Universal (Prevention): Addresses entire population (neighborhood, school, community, etc.) 815=Critical Incident Debriefing: Critical Incident Team members use this code to specify time spent in response to community based critical events. 816=Hostage Negotiation: Hostage Negotiations Team members use this code for time spent providing this specialized service. 817=Community Training: Community-based training provided through Behavioral Health.

73 73 Chapter 8 SCOPE OF PRACTICE/COMPETENCE Staff must only provide services that are within their scope of practice and scope of competency. Scope of practice refers to how the law defines what members of a licensed profession may do in their licensed practice. It applies to the profession as a whole. Scope of competence refers to those practices for which an individual member of the profession has been adequately trained. Some services are provided under the direction of another licensed practitioner. "Under the direction of" means that the individual directing service is acting as a clinical team leader, providing direct or functional supervision of service delivery, or review, approval and signing client plans. An individual directing a service is not required to be physically present at the service site to exercise direction. The licensed professional directing a service assumes ultimate responsibility for the Rehabilitative Mental Health Service provided. Services are provided under the direction of a physician, a psychologist, a waivered psychologist, a licensed clinical social worker, a registered licensed clinical social worker, a marriage and family therapist, a registered marriage and family therapist, or a registered nurse (including a certified nurse specialist, or a nurse practitioner). 37 "Waivered/Registered Professional" means: For a psychologist candidate, an individual employed or under contract to provide services as a psychologist who is gaining the experience required for licensure and who has been granted a professional licensing waiver to the extent authorized under State law; or For a marriage and family therapist candidate or a licensed clinical social worker candidate, an individual who has registered with the corresponding state licensing authority for marriage and family therapists or clinical social workers to obtain supervised clinical hours for marriage and family therapist or clinical social worker licensure, to the extent authorized under state law. 37 State Plan Amendment # Rehabilitative Mental Health Services

74 74 BEHAVIORAL HEALTH PROFESSIONAL LICENSES AND CLASSIFICATIONS Below are tables containing the most common licenses or professional classifications in the Behavioral Health field, with brief definitions and characteristics. In conjunction with information and tables from the preceding sections, these following tables can be used to help further clarify what clinical activities are within the scope of practice of particular professionals. Title AA, Bachelor s, and/or Accrued Experience Definitions/Characteristics MHRS (Mental Health Rehabilitation Specialist) Possesses a bachelor s degree (BS or BA) in a mental health related field and a minimum of four (4) years of experience in a mental health setting as a specialist in the fields of physical restoration, social adjustment, or vocational adjustment. Or, an associate arts degree and a minimum of six (6) years of experience in a mental health setting. Or, graduate education may be substituted for the experience on a year-for-year basis. For example, someone with a bachelor s degree, 2 years of graduate school, and 2 years of experience in a mental health setting can qualify to be an MHRS. Social Worker III Possesses a bachelor s degree (BS or BA) in a mental health related field and minimum of two years of experience providing direct client services in the mental health field. Other, Unlicensed Any other direct service staff providing client support services that does not meet any of the other specified licensure or classification definitions/characteristics.

75 75 Title Graduate School (pre-master s or pre-doctoral) Definitions/Characteristics Psychologist Intern (pre-doctoral) Completed academic courses but have not been awarded their doctoral degree. Completing one of the final steps of clinical training, which is one year of full-time work in a clinical setting supervised by a licensed psychologist. Intern status requires a formal agreement between the student s school and the licensed psychologist that is providing supervision. Psychologist Trainee (pre-doctoral) In the process of completing a qualifying doctoral degree. Often called Practicum Students. Receiving academic credit while acquiring hands-on experience in psychology by working within a variety of community agencies, institutions, businesses, and industrial settings. Supervised by a licensed psychologist. MSW Intern In the process of completing an accredited Masters of Social Work program. Not officially registered with the CA Board of Behavioral Sciences (BBS); does not have a BBS registration certificate or number. Completing clinical hours as part of their graduate school internship field placement. MFT Trainee In the process of completing a qualifying doctorate or master s program. Not officially registered with the CA Board of Behavioral Sciences (BBS); does not have a BBS registration certificate or number. Completing clinical hours as part of their graduate school trainee practicum course. LPCC Trainee In the process of completing a qualifying doctorate or master s program. Not officially registered with the CA Board of Behavioral Sciences (BBS); does not have a BBS registration certificate or number. Completing clinical hours as part of their graduate school trainee practicum course.

76 76 Title Post-Master s, Pre-License Definitions/Characteristics ASW (Associate Social Worker) Completed an accredited Masters of Social Work (MSW) program. In the process of obtaining clinical hours towards a LCSW license Registered with the CA Board of Behavioral Sciences (BBS) as an ASW Possesses a current BBS registration certificate (which contains a valid BBS registration number) MFTI (Marriage and Family Therapy Intern ) Completed a qualifying Doctorate or Master s degree. In the process of obtaining clinical hours towards an MFT license Registered with the CA Board of Behavioral Sciences (BBS) as an IMF (this is the official BBS title but it is interchangeable with MFTI) Possesses a current BBS registration certificate (which contains a valid BBS registration number) LPCCI (Licensed Professional Clinical Counselor Intern) Completed a qualifying Doctorate or Master s degree. In the process of obtaining clinical hours towards an LPCC license Registered with the CA Board of Behavioral Sciences (BBS) as an LPCCI Possesses a current BBS registration certificate (which contains a valid BBS registration number) Title Licensed Definitions/Characteristics Psychologist (Licensed) Licensed by the CA Board of Psychology Possesses a current CA Board of Psychology license certificate (which contains a valid license number) Psychologist (Waivered) Issued a waiver by the State of CA Department of Mental Health to practice psychology in CA. Possess valid waiver. Waiver is limited to 5 years. LCSW (Licensed Clinical Social Worker) Licensed by the CA Board of Behavioral Sciences (BBS) Possesses a current BBS license certificate (which contains a valid BBS license number) MFT (Licensed Marriage and Family Therapist) Licensed by the CA Board of Behavioral Sciences (BBS) Possesses a current BBS license certificate (which contains a valid BBS license number) LPCC (Licensed Professional Clinical Counselor) Licensed by the CA Board of Behavioral Sciences (BBS) Possesses a current BBS license certificate (which contains a valid BBS license number)

77 77 WHO CAN BILL WHAT CODES? Code Eligible Provider 201, 202, 208 Intensive Care Coordination All direct service staff (not including admin support) 221, 222, 228 Intensive Home Based Services All direct service staff (not including admin support) 271 & 272 Outpatient Crisis Intervention All direct service staff (not including admin support) 301 Case Management All direct service staff (not including admin support) 302 Case Management (school based team only) All direct service staff (not including admin support) 311 Collateral All direct service staff (not including admin support) 330 Non-Billable All direct service staff (not including admin support) 331 Assessment *Licensed/Registered/Waivered Staff and Trainees ONLY 332 Assessment (school based team only) *Licensed/Registered/Waivered Staff and Trainees ONLY 341 Individual Therapy *Licensed/Registered/Waivered Staff and Trainees ONLY 342 Individual Therapy (school based team only) *Licensed/Registered/Waivered Staff and Trainees ONLY 351 Group Rehabilitation All direct service staff (not including admin support) 353 Group Therapy *Licensed/Registered/Waivered Staff and Trainees ONLY 356 Family Group Counseling All direct service staff (not including admin support) 357 Family Therapy *Licensed/Registered/Waivered Staff and Trainees ONLY 358 Collateral Group Counseling All direct service staff (not including admin support) 361 Medication Support 361T Medication Support Telepsychiatry *Licensed medical staff only 361U Medication Support Urgent appointment 371 Crisis Intervention (Crisis Team ONLY) All direct service staff (not including admin support) 381 Mental Health Rehabilitation All direct service staff (not including admin support) 391 Plan Development All direct service staff (not including admin support) 392 Plan Development (school based team only) All direct service staff (not including admin support) 405 Case Management Lockout All direct service staff (not including admin support) 475 Collateral Lockout All direct service staff (not including admin support) 485 Mental Health Lockout All direct service staff (not including admin support) No Medical Necessity for school-based team clients only: 305 Case Management 315 Collateral 335 Assessment 345 Individual Therapy 355 Group 385 Mental Health Rehab 395 Plan Development No Medical Necessity For All Other Clients: 401 Case Management 411 Collateral 431 Assessment 441 Individual Therapy 451 Group 481 Mental Health Rehab 491 Plan Development (Same as corresponding codes above) (Same as corresponding codes above)

78 78 WHO IS ALLOWED TO PERFORM WHAT CLINICAL ACTIVITIES? MD, PA, RN, Licensed or Waivered Psychologist ASW, LCSW, MFT Intern, MFT, LPCC Intern, LPCC Trainee for ASW, MFT, LPCC, PHD 38, Masters level field placement Staff with BA + 2 years in MH 39 Assessment Yes Yes Yes Yes No No MSE, DX 40 Yes Yes Yes Yes No No Approve Client Plan Yes Yes Yes Yes No No Psych Testing No Yes No No No No Therapy (Individual, Group, Family) Rehab & Intensive Home Based Services Case Management & Intensive Care Coordination Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Staff without BA/BS Or 2 years MH Scope of Practice is defined by CCR, Title 9, Section & and further clarified by DMH Letter No The grid above provides an outline but does not authorize individual practitioners to work outside their own scope of competence. Some staffing classifications require a co-signature. The supervisor clinical supervisor provides clinical supervision using the cosignature as a supervision tool. The Department of Mental Health has specified that a co-signature does not enable someone to provide services beyond his/her scope of practice. 38 Trainee is post BA/BS and pre MA/MS/PhD 39 Staff with BA/BS in Mental Health Related Field or with 2 years in Mental Health 40 MSE= Mental Status Exam, Dx = 5 axis diagnosis

79 79 CONTROLLED SUBSTANCES UTILIZATION REVIEW SYSTEM (CURES) Monterey County Behavioral Health is committed to the reduction of prescription drug abuse and diversion without affecting legitimate medical practice or patient care. The Controlled Substance Utilization Review and Evaluations System (CURES 2.0) CURES and Prescription Drug Monitoring Program (PDPM) database can assist health practitioners identify, intervene, and deter abuse and diversion of Schedule II through IV controlled substances. California law (Health and Safety Code Section ) requires all California licensed prescribers authorized to prescribe scheduled drugs to register for access to CURES 2.0 by July 1, 2016 or upon issuance of a Drug Enforcement Administration Controlled Substance Registration Certificate, whichever occurs later. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and confidentiality and disclosure provisions of California law cover the information contained in CURES 2.0. Access to CURES 2.0 is limited to licensed prescribers and licensed pharmacists strictly for patients in their direct care; and regulatory board staff and law enforcement personnel for official oversight or investigatory purposes. All Monterey County Behavioral Health prescribers shall register for CURES. 41 Applicants must complete the online registration form and provide a valid address, medical or pharmacist license number, and DEA registration certificate number (prescribers only.) DOJ will validate identity and license electronically with the Department of Consumer Affairs and the Drug Enforcement Administration. MCBH physicians are responsible for accessing the database and reviewing the patient activity reports (PAR) prior to providing any Schedule II, III and IV controlled substance prescriptions. Documentation 1. Once the PAR has been reviewed, the prescribing physician is responsible for documenting a complete assessment in the electronic medical record. 2. Assessment should include all relevant clinical information (diagnosis, prognosis and need for treatment), risk and protective factors, and data from the PAR, in support of the physician s decision to prescribe or not prescribe a Schedule II through IV controlled substance for the treatment of a primary mental health disorder. 41 MCBH Policy 509

80 80 Chapter 9 EVIDENCE-BASED PRACTICE (EBP) Monterey County Behavioral Health Bureau supports and encourages the use of Evidence-Based Practices (EBP) as well as Promising Emerging Practices (PEP) in the treatment of clients to support resiliency, recovery, and wellness. EBP s have demonstrated, through research and practice, to be an effective modality in treating different types of mental health illnesses. EBP is the integration of 1) the best available research; 2) clinical expertise; and 3) the context of patient characteristics, culture, and preferences. Evidence-Based Practice was included in the President s New Freedom Commission and defined as a range of treatment and services of well-documented effectiveness. An evidence-based practice has been, or is being, evaluated and meets the following criteria: Has some quantitative and qualitative data showing positive outcomes, but does not yet have enough research or replication to support generalized positive public health outcomes. Has been subject to expert/peer review that has determined that a particular approach or strategy has a significant level of evidence of effectiveness in public health research literature. There are other practices that show promise in the treatment of different types of mental illnesses. These are called Promising Emerging Practices (PEP). They include those practices for which the scientific evidence is building and which address a widely held client need or gap in our service system. Monterey County has integrated a list of EBP and PEP into the clinical progress notes to encourage use and identification of those practices that are likely to help with each client s recovery and wellness. Note: If two EBP or PEP were used, the clinician should identify (select) the primary modality used during the delivery of service. If no EBP or PEP was utilized during the service provided, an entry of none should be identified prior to finalizing the progress note. Below is the list of EBP that are available in MyAVATAR: Parent-Child Interaction Therapy (PCIT) o A treatment program for young children (ages 2-7) with externalized behaviors that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. Parents are taught specific skills to establish or strengthen a nurturing and secure relationship with their child while encouraging prosocial behavior and discouraging negative behavior. Attachment-Based Family Therapy (ABFT) o A psychotherapeutic model with a foundation in attachment theory. It is based on the belief that strong relationships within families can buffer against the risk of adolescent depression or suicide and help in the recovery process; to help children develop a healthy sense of self, trust in others, and better capacity for independence and affect regulation. Family Psychoeducation o A treatment modality designed to help individuals with mental illness attain as rich and full participation in the usual life of the community as possible. The focus is on informing families and support people about mental illness, developing coping skills, solving problems, creating social supports, and developing an alliance between consumers, practitioners, and their families or other support people.

81 81 Seven Challenges o A treatment for adolescents with drug problems. The goals are to motivate a decision and commitment to change and to support success in implementing the desired changes. Help youth think through their own decisions about their lives and their use of alcohol and other drugs teaching youth to identify and work on the issues most relevant to them. Helps address their drug problems as well as their co-occurring life skill deficits, situational problems, and psychological problems. Aggression Replacement Training (ART) o The intervention program for aggressive young children and adolescents in K-grade 12. The program aims to improve psychological skill competence, anger control, and moral reasoning and social problem-solving skills. Brief Strategic Family Therapy (BSFT) o Therapy designed to (1) prevent, reduce, and/or treat adolescent behavior problems such as drug use, conduct problems, delinquency, sexually risky behavior, aggressive/violent behavior, and association with antisocial peers; (2) improve prosocial behaviors such as school attendance and performance; and (3) improve family functioning, including effective parental leadership and management, positive parenting, and parental involvement with the child and his or her peers and school. Attachment-Based Dyadic Therapy o Therapeutic model designed to support and strengthen the relationship between a child and his or her parent (or caregiver) as a vehicle for restoring the child's sense of safety, attachment, and appropriate affect. It also aims at improving the child's cognitive, behavioral, and social functioning. Matrix o An intensive outpatient treatment approach for stimulant abuse and dependence where clients learn about issues critical to addiction and relapse. They receive direction and support, become familiar with self-help programs, and are monitored for drug use by urine testing. Seeking Safety o A present-focused treatment for clients with a history of trauma and substance abuse focusing on coping skills and psychoeducation. It follows 5 key principles: (1) safety as the overarching goal; (2) integrated treatment; (3) a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse; (4) four content areas: cognitive, behavioral, interpersonal, and case management; and (5) attention to clinician processes. Motivational Interviewing (MI) o A goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence. The operational assumption in MI is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change. Therefore, the examination and resolution of ambivalence becomes its key goal. Dialectical Behavioral Therapy (DBT) o A cognitive-behavioral treatment approach using 2 key characteristics: (1) a behavioral, problem-solving focus blended with acceptance-based strategies; and (2) an emphasis on dialectical processes. It emphasizes balancing behavioral change, problem-solving, emotional regulation with validation, mindfulness, and acceptance.

82 82 Eye Movement Desensitization & Reprocessing (EMDR) o A one-on-one form of psychotherapy that is designed to reduce trauma-related stress, anxiety, and depression symptoms associated with posttraumatic stress disorder (PTSD) and to improve overall mental health functioning. Cognitive Behavioral Therapy (CBT) o A form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. CBT is used to help clients overcome their difficulties by changing their thinking, behavior, and emotional responses. Intensive Community Team (ICT) o A team treatment approach designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness. Triple P (Positive Parenting Program) o A system of parenting interventions for families with children ages 0-8, which seeks to strengthen parenting skills and prevent dysfunctional parenting. The goal is to prevent child maltreatment and emotional, behavioral, and developmental problems. Intensive Family Preservation and Reunification Services (HOMEBUILDERS) o Provides intensive, in-home crisis intervention, counseling, and life-skills education for families who have children at imminent risk of placement in state-funded care to prevent the unnecessary out-of-home placement of children. Staff use intensive, on-site intervention, and to teach families new problem-solving skills to prevent future crises. The program provides crisis intervention and skill building, involves the family in the child's treatment, and broadens the continuum of care so that children are able to avoid the trauma and stigma of psychiatric hospitalization or residential treatment. WELLNESS RECOVERY ACTION PLAN (WRAP) Wellness Recovery Action Plan (WRAP) is described as a structured system that helps individuals track uncomfortable feelings and behaviors and develop planned responses to reduce, modify or eliminate these feelings and behaviors. WRAP was developed by a group of individuals who were trying to find their own ways of effectively dealing with their mental health issues. A WRAP also acts as a plan that can tell others what an individual needs when the individual feels so badly that they cannot make decisions for themselves and need support to stay safe. WRAP is used all over the world to support people with struggling with challenges including (but not limited to) trauma, depression, anxiety, substance abuse, posttraumatic stress disorder as well as physical health concerns such as diabetes. WRAP supports individuals with maintaining their wellness and taking control over their lives. WRAP is based on empowerment and personal responsibility and it takes a holistic approach to recovery which encourages a focus on wellness and strengths rather than on what is not going well. WRAP trainings are provided by Monterey County Behavioral Health to introduce the WRAP system to practitioners and assist them with utilizing a WRAP with clients.

83 83 PROMISING EMERGING PRACTICES (PEP) Promising Emerging Practices are those practices for which the scientific evidence is building and which address a widely held client need or gap in our service system. These include supported housing and various approaches. Joven Noble o A comprehensive indigenous-based youth leadership development program that supports and guides young men through their manhood "rites of passage" process. It also focuses on the prevention of substance abuse, teen pregnancy, relationship violence, gang violence and school failure. Xinachtli o A comprehensive indigenous-based youth leadership development program that supports and guides young women through their female "rites of passage" process. It also focuses on the prevention of substance abuse, teen pregnancy, relationship violence, gang violence and school failure. Cara y Corazon o A culturally-based family strengthening/community mobilization program that assists parents and other extended family to raise and teach their children in with a positive bicultural base. Applied Behavioral Analysis (ABA) o A natural science approach to understanding student academic and social behavior; identifying those variables that educators can control that have an impact on student performance; starts from the assumption that by arranging for effective consequences to follow important educational behaviors -- either academic or social -- educators can influence the frequency of these behaviors. Thinking for a Change (T4C) o An integrated, cognitive behavioral change program for offenders that includes cognitive restructuring, social skills development, and development of problem solving skills for adults and juveniles, both male and female; designed for delivery to small groups in 25 lessons. Cannabis Youth Treatment (CYT) o The Cannabis Youth Treatment Series is a five-volume resource for substance abuse treatment professionals that provide a unique perspective on treating adolescents for marijuana use. They include: 1) Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users; 2) Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement; 3) Family Support Network for Adolescent Cannabis Users; 4) The Adolescent Community Reinforcement Approach for Adolescent Cannabis Users; and 5) Multidimensional Family Therapy for Adolescent Cannabis. Juvenile Sex Offender Treatment (JSORT) Trauma Focused Cognitive Behavior Therapy (TF-CBT) o A psychosocial treatment model designed to treat posttraumatic stress and related emotional and behavioral problems in children and adolescents. TF-CBT is generally delivered in sessions of individual and parent-child therapy. It also may be provided in the context of a longer-term treatment process or in a group therapy format.

84 84 Chapter 10 FULL-SERVICE PARTNERSHIP (FSP) Full- Service Partnership (FSP) Mental Health Service Providers work in partnership with clients, their family, caregivers, other providers, and community to provide a full range of services. These services include planning, policy development, service delivery and evaluation in areas such as drop-in centers, peer support centers, crisis services, case management programs, self-help groups, family partnerships, parent/family education, and consumer provided training and advocacy services while taking into consideration the individual s goals, strengths, needs, race, culture, concerns, and motivations. Each site is responsible for maintaining outcome measurements and data collection based on the four age groupings as specified in the Community Services and Supports (CSS) Plans: Youth (ages 0-15) Transitional Age Youth (ages 16-25) Adults (ages 26-59) Older Adults (ages 60+) The following forms are required for this program: Outcome Measurements Application Baseline (Partnership Assessment Form - PAF) KEC (Key Event Change) 3M forms (Quarterly Assessment) Outcome Measurements Application Baseline (Partnership Assessment Form- PAF): A baseline assessment should be completed within the first 30 days after starting the FSP. The PAF is done at time of entry into an FSP program to establish baseline. A PAF is valid until the consumer has been dis-enrolled from a program AND a lapse of 365 days has occurred since the PAF was discharged. If your program receives a consumer with an existing PAF, meaning that no lapse of 365 or greater days has occurred between events, then your program must enter a KET for admission into your program. Key Event Tracking Changes (KET): This form is used to enter key events. A program only needs to complete the section of the KET for which you are reporting a change with three exceptions: dis-enrolling a client, transferring a client, or receiving a transferred client. When a consumer changes from one program to another, the Referring program must complete a KET document indicated the transfer. The Receiving program must immediately complete a KET document to complete the transfer process. If a program opens a consumer for FSP services after the consumer has been closed to another FSP program, but less than 365 days have lapsed since the discharge from the previous FSP program, the new program must complete a KET document a PAF should not be completed, unless more than 365 days have lapsed. Note: The changing of an apartment but staying within the same complex does not constitute a need to complete a new form. 3M Forms: The three-month assessment (3M) is due on every three month anniversary of your start date [Baseline Partnership Date the date you first provided FSP services, not outreach and engagement. You must have an episode opening in the Integrated System (IS)]. There is a 15 day window prior to the three month anniversary and 30 days after to complete it.

85 85 Chapter 11 SPECIAL POPULATIONS KATIE A. SUBCLASS As set forth in the Katie A. Settlement Agreement: There are children and youth who have more intensive needs to receive medically necessary mental health services in their own home, a family setting or the most homelike setting appropriate to their needs, in order to facilitate reunification and to meet their needs for safety, permanence and well-being. Children/youth (up to age 21) are considered to be a member of the Katie A. Subclass if they meet the following criteria: Are full scope Medi-Cal (Title XIX) eligible; Have an open child welfare services case {means any of the following: a) child is in foster care; b) child has a voluntary family maintenance case (pre or post, returning home, in foster or relative placement), including both court ordered and by voluntary agreement. It does not include cases in which only emergency response referrals are made}; and Meet the medical necessity criteria for Specialty Mental Health Services (SMHS) as set forth in CCR, Title 9, Section or Section In addition to: Currently being considered for: Wraparound, therapeutic foster care, specialized care rate due to behavioral health needs or other intensive EPSDT services, including but not limited to therapeutic behavioral services or crisis stabilization/intervention (see definitions listed in glossary); OR Currently in or being considered for group home (RCL 10 or above), a psychiatric hospital or 24-hour mental health treatment facility (e.g., psychiatric inpatient hospital, community residential treatment facility); or has experienced three or more placements within 24 months due to behavioral health needs. THERAPEUTIC BEHAVIORAL SERVICES (TBS) Therapeutic behavioral service (TBS) is an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) supplemental specialty mental health service as defined in CCR, Title 9, TBS is an intensive one-to-one, shortterm outpatient treatment intervention for beneficiaries under age 21 with serious emotional problems or mental illness who are experiencing a stressful transition or life crisis and need additional short-term specific support services. TBS must be needed to prevent placement in a group home at Rate Classification Level (RCL) 12 through 14 or a locked facility for the treatment of mental health needs, or to enable a transition from any of those levels to a lower level of residential care. Therapeutic behavioral services are intended to supplement other specialty mental health services by addressing the target behavior(s) or symptom(s) that are jeopardizing the child/youth s current living situation or planned transition to a to a lower level of placement. The purpose of providing TBS is to further the child/youth s overall treatment goals by providing additional TBS during a short-term period.

86 86 DAY TREATMENT SERVICES There are two types of day treatment services available under CCR, Title 9, Chapter 11. Specialty Mental Health Services; Day Treatment Intensive and Day Treatment Rehabilitation. Both therapeutic services are available for 3 hours (halfday) or 4 or more hours (full-day) 7-days a week. They include the following service components: Community meetings, Therapeutic Milieu, at least one time per month-contact with a family member. Day Intensive Services is a structured multi-disciplinary treatment program as an alternative to hospitalization, to avoid placement in a more restrictive setting, or to maintain the client in a community setting. Day Treatment Intensive staffing requirements o One person whose scope of practice includes psychotherapy MUST provide services o One person from the following list to eight clients in attendance, or o Two persons from the following list to more than 12 clients attending during the period the program is open: Physicians Psychologists or related waivered/registered professionals Licensed Clinical Social Workers or related waivered/registered professionals Marriage and Family Therapists or related waivered/registered professionals Registered Nurses Licensed Vocational Nurses Psychiatric Technicians Occupational Therapists Mental Health Rehabilitation Specialists Day Rehabilitation is a structured program of rehabilitation and therapy that provides evaluation, rehabilitation, and mental health services to maintain improve, maintain, or restore personal independence and functioning, consistent with the requirements for learning and development. It is an organized and structured program that provides services to a distinct group of clients. Day Rehabilitation staffing requirements o One person from the following list to ten clients in attendance, or o Two persons from the following list below to more than 12 clients attending during the period the program is open: Physicians Psychologists or related waivered/registered professionals Licensed Clinical Social Workers or related waivered/registered professionals Marriage and Family Therapists or related waivered/registered professionals Registered Nurses Licensed Vocational Nurses Psychiatric Technicians Occupational Therapists Mental Health Rehabilitation Specialists

87 87 Chapter 12 PRODUCTIVITY Monterey County Behavioral Health is dedicated in its effort to excel at providing quality services for the benefit of all its clients and their families. Monterey County Behavioral Health has established a productivity standard for all staff providing mental health services. These standards have been created so that all employees can be fully informed as to the level of productivity they are expected to meet and on what basis their quantity of work will be evaluated. Revenue generating activities are an important source of income for our agency. This income, along with other sources of income, such as grants, allows our agency to offer a broad range of services to our clients. The standard level of productivity for all Behavioral Health clinical staff, defined generally as billable time, is no less than seventy five percent (75%). This means that a minimum of 75% of work hours must be spent on tasks and services that are considered billable (treatment planning, case management, assessment, etc.). Other indirect service codes are also factored in to the productivity report as part of the 75% productivity standards (i.e. vacation time, QI time, etc.). We recognize that portions of tasks completed by practitioners are non-billable and that certain practitioner positions require more time focused on non-billable services. Therefore up to twenty-five percent (25%) of work hours may be spent on non-billable activities, such as meetings, committee participation, and other indirect client services and activities. Here is some basic information regarding productivity: What counts as productive minutes? All direct services provided to clients that are entered through progress notes including non-billable (330) services All time entered in appointment scheduler as service code 802 (QI TIME) All MHSA outreach codes authorized, entered in appointment scheduler, in MHSA programs (810, 811, 812, 813, 814) Service codes involving critical community support and training (815, 816, 817) How many productive minutes do I need? No less than 75% of total work minutes This means that up to 25% of total work minutes may be spent on non-billable activities What are non-billable activities? Meetings Committee participation Indirect client services and activities Trainings How many work minutes are in a day? There are 480 minutes in an 8-hour day Once two 15-minute breaks are subtracted, the total number of work minutes in a day is 450 What happens when I am sick/on vacation? There are several service codes used to calculate back out minutes so that minutes not spent at work don t negatively impact productivity percentage Holidays are automatically backed out Service code 803 is used when an employee is sick or on vacation, and 450 minutes back out should be taken For part-time employees, service code 809 indicates non-working hours. These should be backed out of the appointment scheduler so that percent productivity is only calculated for the hours an employee actually spends at work. Note: For more detailed information, please refer to the breakdown of the 310 Productivity Report and MCBH Policy 145, available on the QI website.

88 88 Chapter 13 EXAMPLES EXAMPLES OF STRENGTHS Strengths refer to individual and environmental factors that increase the likelihood of success. Therefore, it is not only important to recognize individual and family strengths, but to use these strengths to help them reach their full potential and life goals. Motivated to change Has a support system friends, family, etc. Employed/does volunteer work Has skills/competencies: vocational, relational, transportation savvy, activities of daily living Intelligent, artistic, musical, good at sports Has knowledge of his/her disease Sees value in taking medications Has a spiritual program/connected to church Good physical health Adaptive coping skills Capable of independent living Interested in restoring relationships The following examples will show you how treatment plans are different based on the client s current stage of change. The stages of change examples are color coded as follows: Pre-Contemplation Maintenance Contemplation/ Preparation Action

89 89 EXAMPLE OF NARRATIVE SUMMARY AND TREATMENT PLAN BASED ON STAGES OF CHANGE DE is an 8-year old boy living with paternal grandparents and 2 younger siblings. Grandparents were granted guardianship of kids in 1/2010; biological parents were struggling to reunify with children. DE is severely affected by combination of variables, including in-utero exposure to drugs and violence, chronic, emotional, physical, verbal abuse, and neglect for first 4 years of life. As a result, DE shows difficulty in social, emotional, behavioral, and cognitive disturbances as evidenced by difficulty in getting along with peers, expressing his needs without yelling, threatening to harm himself by hitting himself on the head with his hands when he doesn t get his way, often not following directions from adults or authority figures, ignoring directions by grandmother, easily frustrated with situations at home and school, and learning difficulties. DE has experienced some stability, since living with his legal guardians, but requires much support. He enjoys playing X- Box, watching cartoons, and likes spending time with his siblings. DE stated he enjoys his recess time because he can run around and that makes him feel good. DE reports he would like to play the drums. DE stated he enjoys playing with his little brother and sister, but sometimes they cry too much and grandparents give them what they want. DE is in the contemplative stage of change as he is agreeable to meeting with school therapist and with psychiatrist. DE states that he has gone to group in previous school setting and it was okay to go again. DE states that he often gets in trouble with the teacher when yells things to him from across the room. DE acknowledged that there have been times when he has just hit his head [with his hands] because he is frustrated and sad. He describes often time feeling frustrated at home because they [grandparents] have too many rules. While the client is in the contemplative state of change in treatment for him, challenges in family dynamics (communication patterns) continue to arise and must be addressed in order to help client meet his emotional needs. Family challenges include, ineffective communication patterns, setting healthy boundaries and demonstrating consistency in setting consequences or praise, and negative interactional patterns between family members. DE s grandmother s communications patterns/responses appear to trigger DE s trauma responses on a consistent basis, making changes more difficult. The degree of environmental stress is evident as DE describes significant tension in that relationship as evidenced by client s statements that grandmother is mean to him. In order to assist DE s progress in treatment, family therapy is warranted. The family is in the precontemplative stage of change and they believed the issues lies within DE, his siblings, and the lack of parenting by his parents. Below are examples if this client/family was in the precontemplative stage: Pre-contemplation (Problem) Barrier or Challenge to Wellness (Goal) My Hope Goal (Objective) A Step I will take to work towards my goals (Interventions) Supports to help me reach my goals DE s Grandparents are unsure how they can better help DE to communicate needs/concerns in healthier manner. Grandmother has difficulty with her communication with DE when DE is feeling overwhelmed and hurts himself by hitting his head using his hands. [Grandmother] I am willing to talk about what is working in my family. Grandmother and other family members agree to meet with clinician every 2 weeks to discuss what is working well within their family. Family will identify at least 1 thing that may be working, but may be further explored or improved upon that may help DE better express himself. Clinician to meet with Grandmother/family every 2 weeks to explore what is working with the family and explore 1 area for improvement that may help improve communication and decrease DE s feeling overwhelmed.

90 90 Below are examples if this client/family were in the contemplative stage: Contemplation (Problem) Barrier or Challenge to Wellness (Goal) My Hope Goal Grandmother s current communication style with DE appear to decrease DE s ability to express himself in healthy manner making symptoms of anxiety, threats of self-harm (using his hands to hit self on head) and feelings of overwhelming worse. I (Grandmother) want to learn how I can help DE to talk about what he needs. I plan to try to understand how I can help DE and my family. (Objective) A Step I will take to work towards my goals I (Grandmother) will meet with therapist 1 time every two weeks for family therapy to explore how I can make changes in my responses when DE is trying to communicate with me and express himself. I will learn and use 2 new communication skills to stay in control of my feelings when communicating with DE and other family members. (Interventions) Supports to help me reach my goals Clinician will meet with Grandmother for family therapy every 2 weeks and provide education on healthy communication. Clinician will focus on effects of family dynamics on DE s responses; Clinician to teach grandmother 2 new communication skills that may help support DE s and family s goals. Below are examples if this client/family were in the action stage: Action (Problem) Barrier or Challenge to Wellness Support family s effective communication pattern in order to support/model positive (effective) way to deal with feeling/concerns. DE has history trauma and although has improved in ability to express self in healthy ways, needs further support/modeling in communicating needs when feeling overwhelmed to avoid making threats to harm self. (Goal) My Hope Goal (Objective) A Step I will take to work towards my goals (Interventions) Supports to help me reach my goals I will continue to build my use of the healthy communication skills when communicate with DE and family. I will be able to identify 2 situations in which new communication skills were effective/not effective I (Grandmother) and family will to use I statements and time outs as well as other healthy communication skills in order to model healthy behaviors to DE and family members as evidenced by self report. I will meet with therapist 1 time every 2 weeks for family therapy to discuss ways to keep improving my communication skills and how things are going with DE and family. Therapist will meet with Grandmother every 2 weeks for the next 3 months for family therapy in order to help process and understand how her own feelings/emotions affect her ability to communication with others. Therapist will reinforce use of effective communication skills; Therapist will model, practice, and encourage use of communication skills.

91 Rehabilitation Therapy Case Management Collateral Group 91 EXAMPLE INTERVENTIONS BASED ON THE STAGES OF CHANGE Precontemplation (High Risk/Not Engaged) Contemplation (Poorly Coping/ Engaged) Action (Coping/ Self-Responsible Clinician to meet with client and explore ways therapy or counseling may be helpful in dealing with feelings of hopelessness. Clinician to meet client weekly for individual therapy to identify goals that may help address symptoms of depression and hopelessness; explore and identify alternative coping skills. Clinician to meet client bi-weekly; use CBT to help client continue to make adaptive and positive changes in management of responses to situation, by increasing understanding of how client can continue to take charge of own behaviors. Staff to meet with client to discuss/explore ways staff may help support client in identifying and/or obtaining life goals. CM/BHA to support client with basic living and independent skills that are supportive in meeting client s goals. CM to meet with client bi-weekly to teach and reinforce active role in independent living skills (communication, using bus, picking up prescriptions, and setting medical appointments). Clinician to meet with client and significant support persons to explore and identify 1 way they may help client reach his/her life goals. Clinician to model, educate, and discuss effectiveness of setting healthy boundaries with client as a means to help client reach life goals. CM to provide significant support persons with ongoing education, encouragement, validation, and support in their efforts to help client reach and maintain life goals. CM along with supports persons to evaluate effectiveness and impact of support on client s life goals. Clinician to meet with client to explore and discuss therapeutic groups available, in community and outpatient services, in order to inform client of options, if/when ready. CM to explain and/or discuss ways in which group participation has helped others in similar situations. Clinician to teach DBT skills in group setting in order to help client understand influence of ineffective responses during stressful situations. Clinician will educate, encourage, assign homework and practice ways to use emotional regulation skills in getting needs met effectively, in order to support life goals. Clinician to utilize DBT skills in group setting and allow for opportunity to practice skills in group and reinforce use of DBT skills beyond group setting. Process and discuss effectiveness of skills used (diary card) and discuss ways to enhance/modify skills to better meet client s goals.

92 Medication 92 Staff to meet with client and explore reasons for hesitation/ambivalence around medication and about meeting with psychiatrist to talk about how medication may be helpful in supporting client s life goals. During session with psychiatrist, clinician will support client with encouragement to use relaxation skills (deep breathing) to communicate effectively. Clinician to encourage client to verbalize how medication is/is not working to address symptoms of anxiety. Clinician will provide and reinforce psychoeducation. Clinician to participate in session with psychiatrist and reinforce use of relaxation skills to manage symptoms of anxiety in order to effectively communicate concerns and benefits of taking medication as well as side effects. Clinician to use coaching to encourage use of coping skills. EXAMPLES OF SOME INTERVENTION WORDS Assess Refer Explore Identify Clarify List Discuss Reinforce Evaluate Utilize Encourage Educate Support Arrange Analyze Develop Interpret Reframe Facilitate Practice Connect EXAMPLES OF INTERVENTIONS FOR SPECIFIC PSYCHIATRIC SYMPTOMS ANXIETY Assess reasons for symptoms of anxiety Explore triggers/situations Refer for medication evaluation to address Discuss benefits of taking medication Encourage reading on subject of anxiety Discuss how medication is helping Explore benefits/changes in symptoms Teach relaxation skills Utilize relaxation homework to reinforced skills learned Analyze fears, in logical manner Develop insight into worry/avoidance Identify source of distorted thoughts Encourage use of self-talk exercises Teach thought stopping techniques Identify situations that are anxiety provoking Encourage anxiety provoking exercises Teach/practice problem-solving strategies

93 93 Encourage routine use of strategies Identify coping skills that have helped in the past Validate/reinforce use of coping skills Identify unresolved conflicts and how they play out BORDERLINE PERSONALITY Assess behaviors and thoughts Explore interpersonal skills Explore trauma/abuse Validate distress and difficulties Explore how DBT may be helpful Encourage outside reading on BPD Explore risky behaviors Explore self-injurious behaviors Improve insight into self-injurious behaviors Assess suicidal behaviors Encourage and practice use of coping skills Identify and work through therapy interfering behaviors Refer for medication evaluation Discuss benefits/effectiveness of medication Educate on skills training Encourage use of skills training skills Explore all self-talk Reinforce use of positive self-talk Explore and identify triggers Review homework Review Diary Card Reinforce completion of homework/diary card Reinforce use of DBT skills Encourage/reinforce trust in own responses

94 94 SUBSTANCE USE/ABUSE Explore drug/alcohol history Refer for physical exam to primary care physician Encourage follow up with physician Support and encourage evaluation for psychotropic medication Discuss benefits/effectiveness of medication Encourage participation in appointments with psychiatrist List/identify negative consequences of substance use/abuse Educate on consequences of substance use on mental health Encourage to remain open to discussion around denial/acceptance Encourage participation in AA/NA Support participation of AA/NA Refer to inpatient/outpatient program Support/reinforce client s participation in substance abuse treatment Facilitate/explore understanding of risk factors List positive aspects of sobriety Reinforce development of substance free relationships Review effects of negative peer influences Encourage exercise and social activities that do not include substances Encourage positive change in living situation Identify positive aspects of sobriety on family unit/social support system Reinforce working on sobriety Explore effects of self-talk Reframe negative self-talk Assess stress management skills Teach stress management skills Reinforce use of stress management skills Explore effective after-care plan TRAUMA Work together on building trust Explore issues around trust Teach/explore trust in others Research family dynamics and how they play out Explore effects of childhood experiences Encourage healthy expression of feelings Encourage use of journaling Encourage outside reading on trauma Explore how trauma impacts parenting patterns Educate on dissociation as a coping response Explore history of dissociative experiences Support confronting of perpetrator Utilize empty-chair exercise to work through trauma Explore/identify benefits of forgiveness Explore roles of victim and survivor and how they are playing out

95 95 DEPENDENCY Explore history of dependency on others Identify how fear of disappointing others affects functioning List positive aspects of self Assign positive affirmations Identify how distorted thoughts affect understanding Explore fears of independence Identify ways to increase independence Teach and reinforce positive self-talk Explore effects of sensitivity to criticism Educate on co-dependency Explore issues around co-dependency Educate on benefits of assertiveness skills Teach/practice assertiveness skills Reinforce/encourage assertiveness Encourage use of No Identify and list steps toward independence Identify ways of giving without receiving Teach about healthy boundaries Practice/reinforce use of healthy boundaries Model healthy boundaries Encourage decision making DEPRESSION Assess history of depressed mood Identify symptoms of depression Identify what behaviors associated with depression Explore/assess level of risk Assess/monitor suicide potential and risk Teach and identify coping skills to decrease suicide risks Identify patterns of depression Encourage journaling feelings as coping skill Identify support system Develop WRAP plan Encourage use of WRAP plan Encourage/reinforce positive self-talk Explore issues of unresolved grief/loss Teach/identify coping skills to manage interpersonal problems Reinforce/recommend physical activity Monitor and encourage self-care (hygiene/grooming) Normalize feelings of sadness and responses Explore potential reasons for sadness/pain Connect anger/guilt with depression

96 96 FAMILY CONFLICT Explore patterns of conflict within the family Teach conflict resolution Explore familial communication patterns Facilitate family communication Identify how family patterns of conflict and communication are played out Facilitate healthy expression of feelings/concerns Reinforce use of healthy expression of feelings Identify/reinforce family strengths List ways family may participate in healthy activities in community Define roles in the family Identify areas of strength that may be used to parent Teach/practice/model parenting techniques Identify patterns of dependency on family members Identify feelings of fear/guilt/disappointment Explore/identify patterns of dependency within family unit BIPOLAR DISORDER Explore symptoms concerning bipolar disorder Educate on mania and depression Use reflection to identify mania/depression behaviors Educate on risky behaviors associated with mania Explore behaviors associated with mania Identify coping skills Identify early warning signs and energy levels Explore grandiosity Encourage/discuss effectiveness of medication Encourage participation in appointments with psychiatrist Identify effects of tress on psychiatric symptoms Identify/discuss issues of impulsivity Discuss consequences of impulsivity Model/reinforce effective communication Utilize cognitive reframe Encourage education on bipolar disorder MEDICAL ISSUES Gather information regarding medical history Identify who is primary care physician Encourage follow through with medical recommendations Identify/explore negative consequences of no following through Educate on grief/loss issues and impact on openness to medical treatment Explore denial around recommended medical treatment/follow up Process feelings of fear/ambivalence/anxiety

97 Normalize feelings of fear/ambivalence/anxiety Teach relaxation exercises Monitor/encourage compliance with medical recommendations Reinforce use of coping skills during medical appointments Reinforce communication skills to ask for clarity Reinforce assertiveness skills Encourage use of social support system 97

98 98 EXAMPLES OF PROGRESS NOTES EXAMPLE COLLATERAL SERVICE F: Case manager met with client and the client s family (biological mother and aunt) at the office to discuss ways to help support client in attaining goal of re-entering the workforce as symptoms of depression and communication of needs in a healthy manner previously effected client s ability to remain employed. Client was in agreement to include family in session for added support. I: As a means to assist the client with attaining her life goal of re-entering the workforce, this Case Manager met with the client s family and modeled healthy communication and boundary setting. Case Manager educated the client s family on healthy ways to help client attain goals by taking time to listen to the client and family s concerns without interruption or providing unsolicited feedback. As a means to encourage pro social communication, this Case Manager encouraged the client to use the phrase I just need you to listen when starting a conversation with her family. Client s family was encouraged to continue participation in monthly family support group for further development of skills. R: Client s family was able to identify communication patterns that may be helpful in order to improve support with communication. For example, the family was open to listening for a key phrase during interactions with client. Client was able to identify a key phrase as well as being opened to using the skill when communicating with her family. Client was opened to listening how this skill may also be useful for overall communication with others, including employers. Family reported being open to making an effort to attend a monthly family support group. P: Clinician will continue to engage and utilize social support system to help address client s needs. Clinician will also continue to work with client to identify and practice healthy coping skills in order to support client with returning to the workforce. Example of Goals Linked from Treatment Plan Problem: At times, family has contacted clinician to discuss client s behaviors that negatively impact home environment. Client has difficulty with healthy boundaries and often argues with family causing strain in their relationship and ability to communicate each other s needs effectively. Goal: Strengthen family support by including identification and education on ways to help client by setting healthy boundaries. Objective: My family will talk with clinician on ways to improve understanding and knowledge of my needs and ways to support me in reaching life goals. Intervention: Utilize social support system to a help client attain life goals. Utilize psychosocial education, validation, family support group, and modeling.

99 99 EXAMPLE INDIVIDUAL REHABILITATION F: Clinician met with client in in the community for a one-on-one session to improve client s relaxation skills as a means to avoid reactivity and feelings of anger during stressful situations. Client was prepared for session as evidenced by waiting for this clinician outside and being actively engaged in role plays throughout the session. I: In order to help client decrease angry outbursts, clinician encouraged the client to utilize coping skills that included deep breathing relaxation exercises and taking a quick time-out instead of reacting to situations. In order to further practice coping skills to manage anger, clinician and client role-played a recent situation where client reacted to the situation in angry manner and practiced different responses the client could have had. Client was encouraged to use relaxation exercises at least 2x during the following week. R: Client reports feelings frustrated when people don t understand me.they ask me the same question over and over..they make me mad. Client was able to describe a situation when she felt overwhelmed by feelings and as a result he yelled at her mother. During role-play, client was able to identify a couple of areas where taking a breath and a quick time-out may have been helpful. Client reported participation in role-play was beneficial and agreed to practice coping skill at least 2 times during the next week, if the situation arises. P: Clinician to meet with client in one week and process if the use of the practiced coping skills was helpful or not helpful during stressful situations. Example Goals Linked from Treatment Plan P: Client describes easily getting angry and losing control and getting into verbal arguments with peers and family members (baseline 2 times nearly daily). Client often times feels saddened by her behaviors in these situations. Client would like to improve her ability to communicate in a healthy manner in order to avoid arguments that lead to further frustration and isolation from her friends and family. G: I want to get along with my friends and family. O: Client to meet with clinician every 2 weeks to learn and practice ways to better manage situations where I feel I may lose control and yell at others. I will learn and use relaxation skills (deep breathing, mindfulness, time-outs, etc.) at least 1-time a day to try and stay in control of my feelings and decrease my yelling at others. I will try this for the next 3 months I: Clinician to teach and practice relaxation techniques in order to help client stay in control of feelings in order to help improve her ability to better get along with her friends and family. Clinician will discuss how relaxation techniques may or may not be working.

100 100 EXAMPLE CASE MANAGEMENT SERVICE F: Case manager met with client in office. Client was late to session and was irritable. Client reports having difficulty understanding why he needs to move out of the board and care and feels confused about where to begin to look for a new place to live. Client has received 30-day notice to vacate due to non-compliance with rules (smoking in the room, yelling at roommate, and disturbing others by asking for money). Client was cooperative during the session but needed redirection due to feeling angry and frustrated about being asked to leave. I: Case Manager met with client to discuss housing options due to receiving a notice to vacate and to explore housing alternatives, including local shelters. Discussed reasons for dismissal in hopes of helping client understand the impact of their behaviors. Discussed and reinforced need for healthy communication and following rules that keep others safe (no smoking in rooms). Helped client identify one behavior to keep an eye on in order to increase understanding of his behavior on the situation and avoid behavior in the future. Case Manger provided support through validating the client s feelings of worry and encouraged client to remain open to discussion/explore on how choice in behaviors are negatively impacting ability to remain in housing for extended periods of time. R: Client was irritable, but cooperative. Client had difficulty accepting notice to vacate as he reports others don t follow the rules, either. Client was unable to identify social support system for temporary housing. Client was open to referral to other board and care settings. Client was able to identify stays at board and care. Client had difficulty with understanding he is unable, at this time, to provide for his own basic needs and continues to require board and care setting to ensure safety. Discussed alternative Board and Care homes for consideration. P: Case Manager will meet with client and contact board and care homes to inquire regarding availability. Case Manager will advocate on client s behalf, in order to assist client with finding new place to live. Case Manger will explore what to expect during the interview and will provide client with support by asking questions about expectations. Example Goals Linked from Treatment Plan P: Client has history of difficulty with taking care of his/her basic living skills and is currently living in a Board & Care setting. Client has history of difficulty with following rules and has been asked to move-out within the next 30 days. Client becomes easily confused followed by frustration. Client has difficulty community his needs in a healthy manner and resolves to raising his voice when talking to people. G: I want to work with case manager on finding a new place to live. I don t think I can find a place by myself. O: I will meet with case manager every week to find a different place to live. I will write down questions to ask the new place. I will go to interviews until I find a new place. I: Case manager to work with me in exploring housing options and help develop questions to ask the new place. Case Manager to support client with staying organized and focused in finding housing; CM to complete referrals and documentation necessary to support client s transition to housing.

101 101 EXAMPLE CASE MANAGEMENT SERVICE- EXAMPLE 2 F: Case Manger contacted 3 board and care facilities in the area by telephone as a means to gather additional information about availability and admission requirements given that the client s current mental health needs require support from a board and care to ensure client s safety. I: Case Manager, along with client, contacted 3 different board and care settings and inquired regarding availability. Inquired regarding interview time/date and process. Scheduled appointments with all 3 board and care facilities for next week to ensure that the client is able to be admitted in a timely manner. Helped client identify 3 questions to ask during the interview. R: Board and Care administrators discussed their current availability as well as the interview and intake process. All administrators were able to arrange interviews for next week and clarified the documents that the client will need to bring. P: Case Manger to remind client to bring questions to ask the interviewer as client is easily confused when feeling overwhelmed. Case Manager will provide client with support and encouragement in asking 3 questions of interviewee in order to facilitate interview and admission to new place Example Goals Linked from Treatment Plan P: Client has history of difficulty with taking care of his/her basic living skills and is currently living in a Board & Care setting. Client has history of difficulty with following rules and has been asked to move-out within the next 30 days. Client becomes easily confused followed by frustration. Client has difficulty community his needs in a healthy manner and resolves to raising his voice when talking to people. G: Identify alternatives housing options. O: I will meet with case manager every week to find a different place to live. I will write down questions to ask the new place. I will go to interviews until I find a new place. I: Case manager to work with me in exploring housing options and help develop questions to ask the new place. Case Manager to support client with staying organized and focused in finding housing; CM to complete referrals and documentation necessary to support client s transition to housing.

102 102 EXAMPLE MENTAL HEALTH SERVICE FAMILY THERAPY F: Clinician traveled to client s home to meet with the client and his maternal grandparents. Client and family are experiencing high level of stress and need support with helping the client manage anxiety, threats of self harm and feeling overwhelmed. Client and family were open to process feelings/concerns. I: Clinician facilitated communication between family members and allowed time for all the express self and concerns. Reinforced use of healthy communication and modeled such when interacting with all individuals present. Clinician used gently confrontation, active listening, support, and encouragement when an individual struggled with expressing their feelings and assisting them with communicating in a positive manner. Clinician educated the client s grandparents about parenting techniques and ways to set consistent and healthy boundaries for client. Identified previous adaptive coping skill used by each family member in the past. Clinician wrapped up the meeting by identifying the family s strengths to encourage future participation in family therapy sessions and encouraged the family to contact the clinician should they need assistance with addressing their frustration. R: Client tried to control the family session, interrupting conversations and displaying his temperament. Client responded to redirection by clinician. Client identified a difficult day at school, as he was unable to participate in field trip, due to previous behavioral issues. Grandparents reported desire to help client feel better, however, when client does not listen to directives or do chores, it is difficult to get along. Grandmother was open to allowing clinician to confront her responses to client s behaviors. Grandmother had some difficulty with staying on topic and wanting to continue to discuss her frustration, instead of focusing on coping skills and interventions. Family in agreement to take time out, when feeling frustrated in order to avoid conflict and also agreed to contact the clinician should they need assistance with managing frustration related to communicating with the client. P: Clinician will continue to work with client and family to assist them with improving communication, parenting skills, and coping skills to help client attain goal of managing anxiety, decreasing threats of self harm and managing feelings of overwhelm. Example Goals Linked from Treatment Plan P: Grandmother s current communication patterns with DE appear to decrease DE s ability to express self healthy manner making symptoms of anxiety, threats of self-harm, and feeling overwhelmed. G: I (Grandmother) want to help my grandson feel better and work through what is going on. O: I (Grandmother) will meet with counselor 1 per week for individual and/or family therapy to identify ways to support DE s healthy communication. I (Grandmother) will use I statement skills at least on most days and may call therapist for added support when I get too frustrated. I: Therapist to explore, identify, and educate on family dynamics and identify skills to improve communication in order to support/model effective communication to client and support client s progress in dealing with trauma.

103 103 EXAMPLE GROUP REHABILITATION F: Client participated in group therapy in school setting with 5 peers and two facilitators. Client stated he is doing well and appears to be alert. The intention of the group is to provide clients with a safe environment in a supervised group activity. Participation in this group, encourages clients to decrease isolative behaviors, increase proactivepositive peer social skills, improve communication, decision making process, encouraged community involvement, and reinforces interpersonal skills. I: Facilitators provided group with safe and encouraging environment. Facilitators educated client on importance of physical exercise s effects on mood and overall health. Provided opportunity for decision making process by asking group members to choose physical exercises to practice. Provided redirection as necessary to facilitate process. During activities, facilitated group to encourage each other to complete exercises. Facilitators validated client s feelings/concerns/and process. R: Client participated in group decision making process. Client was able to verbalize suggestions effectively to group members. Client was able to be redirected when getting off topic with peers. Client reported feeling good about being able to make some choices as usually people tell him what to do. Client participated in most physical activity exercises. P: Continue to provide safe and encouraging environment for group members. Continue to challenge group members. Continue to support client s life goals. Example Goals Linked from Treatment Plan P: Client has a difficult time expressing and articulating feelings in constructive manner and when unhappy and makes threats to hurt himself to get his way. G: I need to talk when I don t feel good or I am mad. O: I will attend group, in school, to learn how to talk when I am mad instead of just crying and yelling. I may learn how to express my feeling by talking, writing, or drawing instead of yelling to get my way. I will try this until the end of the year. (Baseline: negative threats 5 of 7 days weekly). I: Group facilitators to help client reach his goals through use of group therapy. The group will include different therapeutic interventions on ongoing basis, including psychoeducation, socialization skills, communication skills, and conflict resolution in efforts to help client learn about self and healthy ways of expressing self.

104 104 EXAMPLE GROUP IHBS SERVICE F: Clinician met with the client in order to assist the client with continuing to learn and utilize coping skills to effective manage feelings related to depression and isolation. The client appeared to be in low spirits as evidenced by his hushed tone of voice and stating that there is nothing anyone can do to help me. I: Clinician greeted client and modeled pro social communication skills by engaging the client in a discussion about how his weekend had gone and if he was able to get out of the house at least once as planned. To determine the client s current level of depression this clinician asked the client to rate his depression on a scale of 1 to 10 (ten being very depressed ). This clinician encouraged the client to process what coping skills have and have not worked with regard to managing sadness and encouraged the client to verbalize if he would be interested in attending a support group for individuals who have lost a child as a means to address the sadness related to the death of his daughter. This clinician encouraged the client to review his safety plan to ensure that the client is clear regarding steps he can take if he feels he needs assistance between sessions and reviewed the various coping skills (journaling, mindfulness skills, calling a friend) that can decrease depressive symptoms. R: Client reported that his weekend was okay but stated that he did not really go anywhere as planned because he just did not feel like it. The client reported that his depression was currently at a 5 and that he just wishes that people could understand him. Clinician struggled to verbalize what coping skills help him and continued to state that all he needed was time to get over his sadness. Client reported that he would be willing to attend a support group for people who have lost a child and stated that he planned to attend next week. The client reviewed his safety plan and agreed to follow the steps necessary to request support if needed. P: Client will continue to participate in bereavement group at least 2x per month to assist him with developing and utilizing coping strategies to assist with decreasing sadness over loss. Example Goals Linked from Treatment Plan P: Client has symptoms consistent with schizoaffective disorder. LR presents with depressed mood and lacks motivation in participation in any activities in the community; spends majority of his time at home, watching television, and has minimal contact with family members. Client has no social relationships and reports no interest in building any. Client is able to identify source of depression related to death of daughter (10 months ago). G: I want my daughter back. I just don t know how to not feel so sad. O: I will attend one bereavement support group at least 2 time a month to see if it can be helpful to learn more about depression and to learn how to feel better (coping skills). I will try this for the next 3 months. I: Facilitators will encourage client s participation in group process to address sadness. The intention of this group is to offer individuals an opportunity to identify and learn ways to deal with sadness in a healthy manner. The group will offer opportunity to learn new skills and practice skills in the group setting and away from the group.

105 105 EXAMPLE GROUP ICC SERVICE F: Care Coordinator (CC) met with the Client Family Team (CFT) which consisted of the client, the client s foster parents, Child Welfare Services social worker and the client s County Behavioral Health Aide. I: CC thanked all individuals for attending today s meeting for the purpose of review the progress that the client has made thus far with regard to managing angry feelings in a more constructive manner and decreasing threats of self harm. The CC encouraged the client and each individual present to speak to the progress that the client has made and encouraged each individual to provide input regarding next steps in the treatment process to ensure the client s continued success. The CC noted several community resources that were discussed and reported that he would follow up on these resources for the client and report back to the team when additional information is gathered. The CC reported that based on the client s progress toward his treatment goals that the treatment plan would be updated to reflect current baselines and would be presented to the client and the team next week. The CC provided positive feedback to the client for his hard work toward addressing his goals and encouraged the client to continue to verbalize his needs to his support persons as necessary. R: The client was actively engaged in the CFT as evidenced by his eye contact and remaining seated at the table. He was able to report that the extra support he has been receiving from his foster parents over the past month has been helpful and that sometimes he needs to be reminded of his goals. Each individual present reported that the client has been better able to manage his feelings of frustration in the school and home setting and discussed community resources they feel may be of additional support to the client. All present agree to review the updated treatment plan at the CFT scheduled next week. P: The CC will review and update the client s current treatment plan to reflect current needs and baselines and will present the updated plan to the CFT during next week s scheduled meeting. Example Goals Linked from Treatment Plan P: Client has a difficult time expressing and articulating feelings in constructive manner and when unhappy and makes threats to hurt himself to get his way (Baseline: negative threats 5 of 7 days weekly). G: I need to talk when I don t feel good or I am mad. O: I will meet with my team every month to talk about how things are going. I will make an effort to listen and not talk over people (instead I may write my thoughts down or draw on my paper). I will make an effort to avoid yelling during the meeting. I: my team will meet every month with me to talk about how things are going. Coordinator may remind me to use my skills of journaling, drawing, or listening during the meeting in order to help me reach my goal.

106 106 Chapter 14 LANGUAGE SERVICES Monterey County offer services and support to a diverse community. We believe it is everyone s responsibility to provide the best service to our community members. So often we hear how language can be a barrier for people seeking services and oftentimes the individual making the call or seeking services is doing so for the first time. Taking this step can be scary and the person may be feeling vulnerable, this is why we need to take the necessary steps to assess the individual s needs, even when they may speak a language other than English LANGUAGE LINE Please follow these steps to access the Language Line: All MCBH staff members have access to the Language Line 1-(800) to help assess the individual s needs. Remember that when helping the individual, it is your responsibility to make a risk assessment to ensure the person is not in imminent danger. When a client is in the OFFICE: If you are calling from your OFFICE and the client is present with you, you can use the speaker phone function and follow the directions below.

107 107 When a client is on the TELEPHONE: You will need to use the conference feature on your telephone to complete the call. To initiate a conference call: After the first connection has been made (or your client is holding on the line), press Inquiry or Access 1 or Access 2 button to begin the second call. Dial the number or the extension of the person/party you want to add the conference call. o NOTE: if you are unable to reach the party, Press C (located below the number pad which will hang up the second call. o Return to the original call by pressing the flashing line key. Once the second party answers, press the Number 3 button on your dial pad and the conference call is established. All three parties will be connected. To add another party to the conference call, press the Access 1 or 2 or the Inquiry button and follow the above process. You can add up to seven (7) parties to your conference call. To initial an outbound call with a client: 1. Dial AT&T Language at Enter Client ID: Provide the Language Line representative the following information: 1. Client ID: 2. Organization: Monterey County Health Department: Behavioral Health 3. Personal Code: your last name or your 5 digit employee number 4. Language being requested You will need to wait for the Answer Point to conference in your interpreter. Brief your Interpreter on the Nature of the call. Summarize what you want to accomplish and give any special instructions.

108 108 INDIGENOUS INTERPRETATION SERVICES Please follow these steps to access indigenous interpreting services: Languages include: Mixteco, Triqui, Zapoteco, Chatino, Kanjobal, Amuzgo, Náhuatl, Tarasco, Purépecha, Tlapaneco, Yucateco Maya, Mam, K iché (Quiché), Mixe + more. Step 1: Complete the electronic Interpreter Request Form Step 2: Insert the following information in the specific sections of the form (Top of the form) (Bottom of form) BILLING INFORMATION * Invoice to: sumeshwarsd@co.monterey.ca.us Monterey County *Mail invoice to: (Agency Name): Health Dept. Attn: Shiba Sumeshwar * ddr 1270 Natividad Rd. *Name: appoin ails? Step 3: Submit completed Interpreter Request Form via or fax. To: info@interpretnmf.com Fax: (831) Cc: sumeshwarsd@co.monterey.ca.us To check the status of your request: Judith Pacheco Judith@Natividadfoundation.org Phone: (831)

109 109 INTERPRETER SERVICES Please follow these steps to access interpretation services from the Master List below: Step 1: Clinical staff or Supervising PSR will directly schedule interpretation/translation services Step 2: Send to Monterey County Health Department Bureau Finance Department advising of intent to use interpreter from the Master List below. The body of the should contain: Date scheduled AND name of chosen Vendor. Step 3: Ana Landa, will keep the and it will serve as confirmation that BH staff requested the service. Additionally, if no invoice is received within a reasonable period of time, Ana can make contact with the vendor to track down the invoice. Central Coast Sign Language Interpreters (code: MA, ID: *49) Phone: (831) Fax: (831) gail@ccsignlanguageinterpreters.com Provides sign language only Key Lingo Translations (code: MA, ID: *97) Phone: (925) jim.hostetler@keylingo.com Provides translation & interpretation services for all departments, Language Quest (code: MA, ID: *50) Phone: Fax: info@languagequest.net Provides translation services for all departments, Monterey County Interpreting Services (code: MA, ID: *98) Phone: (831) Fax: (831) Contact: Olivia Wilson Provides translation & interpretation services for all departments, including designated services. Medialocate USA, Inc. (code: MA, ID: *51) Phone: (831) or (800) Fax: (831) Website: Provides translation & interpretation services for all departments, including designated services for Elections Dept. Norma Alvarez (code: MA, ID: *84) Phone: (770) nla1961@gmail.com Provides designated services for Elections Dept. only

110 110 Richard Schneider Enterprises, Inc. (code: MA, ID: *52) Phone: (831) or (800) Fax: (831) Provides translation & interpretation services for all departments, including designated services for Elections Dept. Note special instructions regarding this Interpreter: Andy Nguyen, Vietnamese translation services. Contact Ana Landa at least one week prior to appointment for services from this vendor.

111 111 Chapter 15 APPENDIX SENDING SECURE/ENCRYPTED The confidentiality of medical, psychiatric, and substance use information is protected by State and Federal statutes, rules and regulations. The statues, rules, and regulations require that we protect the client s personal health information (PHI) and personal identifiable information (PII). The law requires we obtain consent from the client/ legal representative prior to the disclosure of PHI, except under specific conditions as indicated by the laws. Confidentiality of client information must be protected at all times. Confidentiality of client information must be protected at all times. There are times when we may need to share PHI information outside of the Monterey County Health Department directory as part of the coordination and delivery of services. When this is the case, in order to uphold confidentiality, staff must use the following procedures for protecting PHI and PII. Safeguards for protecting PHI and PII should be taken to minimize the risk of a potential breach in confidentiality. Do NOT put client name or medical record number in the subject line. If absolutely necessary, please use client initials. Double-check addresses before you hit reply to all to determine if the contains PHI or PII. If PHI or PII information is present, you must send the message via secure . Check to make sure there are no personal addresses before you send an . Monterey County Behavioral Health does to authorize the use of personal s to conduct County business. Ensure this confidentiality statement is on your signature: Confidentiality Notice: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution of this message is prohibited and may be against the law. If you are not the intended recipient, please contact the sender by replying to the original and destroy all copies (electronic and print) of the original message. Sending a Secure Effective September 10, 2016 all staff are required to follow the following procedures for sending an encrypting when sending PHI and PII, as permitted by law. Select Low Importance to send an encrypted/secure . Although it is counterintuitive, the use of Low Importance will send out an encrypted . This method can be used from Microsoft Outlook, online Outlook (from Office 365 Portal) or from your mobile device (those approved for County use)

112 112 Opening a Secure (Receive, view and reply to encrypted messages) A message that is ecrypted by Office 365 Message Encryption is delivered to a recipient s inbox just like any other message, but it contains an HTML file attachment. After opening the attachment, the receipient can select the use of a one-time passcode to view the message on the Office 365 Message Encryption portal. You wil receive an with the one-time password. The includes instructions for viewing the encrypted message, as in the following example:

113 113 You will need to enter the one-time password to view the message. Note: If the recipient is inactive for more than 15 minutes, they are automatically signed out of the encryption portal. You may reply to an encrypted message by choosing Reply or Reply All, and then Send. An encrypted copy of the reply message is sent to the original sender.

114 114 APPROVED ABBREVIATIONS LIST Clear documentation is crucial to client care. Maintaining the integrity of the health record along with the documentation of services provided or services that will be provided in the future is necessary to understanding what the treatment looks like for the client/family. Below is a list of the MCBH approved abbreviations list that you may use when documenting in the client record. Full Word or Term Individual Session 1:1 A Absent Without Leave AWOL Activities of Daily Living ADL Adult Needs and Strengths Assessment ANSA Adult Protective Services APS Against Medical Advice AMA Alcoholics Anonymous AA Appointment Appt As necessary prn As Soon As Possible ASAP At night HS At Once STAT B Be on the lookout BOL or BOLO Behavioral Health BH Blood Pressure BP Board and Care B&C Boyfriend BF Brought in by BIB Brother bro C Case Coordinator CC Case Manager CM Center for Employment Training CET Child Assessment of Needs and Strengths CANS Child Protective Services CPS Client Cl or Clt Community Hospital of the Monterey Peninsula CHOMP Creating New Choices Program CNC Critical Incident Stress Management CISM Crisis Negotiations Team CNT D Danger to Others DTO Danger to Self DTS Delirium Tremens DT Department of Social and Employment Services DSES Department of Social Services DSS Abbreviation

115 115 Developmentally Disabled Diagnosis Disorder Divorced Electroconvulsive Therapy Electroencephalogram Emergency Department Emergency Room Evaluation Every day Every hour Every morning Every night Example Extrapyramidal Symptoms Father Foster Father Foster Mother Four times a day Full-Service Partnership Gastrointestinal Girlfriend Grandfather Grandmother Grave Disability or Gravely Disabled High Blood Pressure History Home Visit Hostage Negotiations Team Individual Individualized Education Plan Information Institution for Mental Disease Intramuscular Intravenous Left message Maternal Grandfather Maternal Grandmother MediCal E F G H I L M DD Dx D/O div ECT EEG ED ER eval QD Qh QAM QPM, QHS e.g. EPS Fa FFa Fmo QID FSP GI GF GFa GMo GD HBP Hx HV HNT Ind IEP info IMD IM IV LM MGFa MGMo MC

116 116 Medication Mental Health Mental Health Rehabilitation Specialist Mental Health Specialist Mental Health Unit Monterey County Behavioral Health Monterey County Sheriff s Office Mother Multi-disciplinary Team Narcotics Anonymous Natividad Medical Center Officer of the Day Orally Paternal Grandfather Paternal Grandmother Penicillin Physician Assistant Police Department Prescription Public Guardian Psychiatric Social Worker Quality Assurance Quality Improvement Quality Management Regarding Re-scheduled Rehabilitation Residential Treatment Return Return to Clinic Rule Out Section 8 Housing Severely Emotionally Disturbed Short Doyle/Medi-Cal Significant Other Sister Skilled Nursing Facility Social Security Administration Social Security Income Social Worker N O P Q R S Meds MH MHRS MHS MHU MCBH MCSO Mo MDT NA NMC OD po PGFa PGMo PCN PA PD Rx PG PSW QA QI QM Re: R/S Rehab Res rtn RTC R/O Sec-8 SED SD/MC S/O sis SNF SSA SSI SW

117 117 Social Worker III SWIII Symptoms Sx T Telephone call TC Tardive Dyskinesia TD Three-times a Day TID Timex x Treatment Tx Two times a day BID V Veterans Administration VA W With w/ Within w/in Within Normal Limits WNL Without w/o Weight Wt Y Year Old Y/O Year Yr

118 118 PRODUCTIVITY REPORT BREAKDOWN 310 Staff Productivity Report 1) This document is based on the content of the 310 Staff Productivity Report available to staff, supervisors, and administrators in MyAvatar. 2) Either the Detail Level Data or Summary Level Data version of the 310 Staff Productivity Report can be used. OR Sections of 310 Staff Productivity Report Used for This Document The following sections of the 310 Report are of most significance for the purpose of this document: 1) Top of 310 Report containing Date Range and Number of Work Days/Minutes 2) Bottom of 310 Report containing the Total Summary for All Days in Time Period

119 119 Components and Equations of the 310 Report 1) The number of work days (A) is based on the number of County business days (which excludes all County holidays) in a given date range (B): IS DERIVED FROM NOTE: The example utilizes 20 work days in the date range from 6/1/2013 to 6/30/2013. The actual number of work days will vary depending upon the date range utilized in the 310 Report. 2) The number of work minutes (C) in a given date range (B) is determined by multiplying 450 minutes per work day by the number of work days (A) in a given date range (B): (# of work days) X (450 work minutes = (# of work minutes) work day) NOTE: The example utilizes 9,000 minutes in 20 work days in the date range from 6/1/2013 to 6/30/2013. The actual number of minutes will vary depending upon the actual amount of work days in the date range utilized in the 310 Report. 3) The 450 minutes per work day is determined by the number of work hours in a day (8 hours), multiplied by 60 minutes per hour minus two 15 minute breaks per work day. (8 hours X (60 minutes - (2 x 15 minutes) = (450 minutes work day) hour) work day) To account for the two 15 minute breaks per work day NOTE: Although an 8 hour workday with 450 minutes is used as part of the calculation, the actual productivity percentage is calculated based on the monthly amount of work minutes to account for 40 hour per week employees with alternative schedules. Staff that work less than 40 hours a week must enter the appropriate 800 code into their MyAvatar Scheduling Calendar to ensure accuracy of their productivity percentage.

120 120 4) The Billed Minutes (D) component of the 310 Report draws the number of minutes from Progress Notes with billable and 330 service codes. 5) The Total Direct Service Time (E) is the Billed Minutes plus all direct service 800 codes from the staff member s MyAvatar Scheduling Calendar: Billed Minutes + All Direct Service 800 Service Codes = Total Direct Service Time The following are considered Direct Service 800 codes: a. 802 Utilization Review/QI b. 811 Outreach and Engagement c. 812 Early Intervention d. 813 Indicated/Selected (Prevention) e. 814 Universal (Prevention) NOTE: Only specialized programs with specific contracts utilize 811, 812, 813, and 814.

121 121 6) Total Backouts is based upon 800 codes that are considered backouts from the staff member s MyAvatar Scheduling Calendar. The 800 codes considered backouts are the following: a. 803 Vacation/Sick b. 809 Non-Working Time c. 815=Critical Incident Debriefing d. 816=Hostage Negotiation e. 817=Community Training These codes can be seen on the 8xx section of this report (far left) 7) Total Work Minutes After Backouts (G) is the number of work minutes possible in a month (C) minus the Total Backouts (F): - =

122 122 8) Percent of Work Hours Productive (H) is the Total Direct Service Time (E) divided by Total Work Minutes After Backout (G): / =