SANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery Page 11 of 5 Programmatic Pol icy and Procedure Section Clinical Sub-section Practices and Services Policy Policy# Service Availability for Routine Conditions 8.301 /'l~ Director's Approval ~~... ~:---- - - f 4~ce Glegnorn, PhD ~ Deputy Director's ~ J} 2-..J.I, /l A Approval -/U lfau.plt) 11.U Pam Fisher, PsyD / / Supersedes: P&P 8- Service Triage: Routine Conditions rev. 9/1/2004 Effective: 4/1/1998 Version: 2.0 Last 8/8/2018 Revised: Date Date I Audit 8/8/2021 Date: 1. PURPOSE/SCOPE 1.1. To ensure procedures for the access of medically necessary specialty mental health and substance use disorder services within the county's Mental Health Plan (MHP) and Drug Medi-Cal Organized Delivery System (DMC-ODS), including referral for routine services, appointment scheduling and after-hours service availability, in accordance with the standards set forth by the California state Department of Health Care Services (DHCS), Title 9 and 22 regulations, and all other relevant state and federal laws and regulations. 2. POLICY 2.1. It is the policy of the (hereafter the "Department") to ensure service availability for all Medi-Cal/Drug Medi-Cal beneficiaries and community members who may request specialty mental health and/or substance use disorder service referrals and authorization. Department-operated programs and network provider staff will conduct effective and efficient in-person and telephone screenings to evaluate the need for specialty mental health and/or substance use disorder services based upon medical necessity, degree of impairment and presentation of acute or urgent 1 symptoms. 3. SERVICE AVAILABILITY PROCEDURES 3.1. Access Line staff will respond to telephone inquiries or faxed requests from individuals seeking services or by others on behalf of an individual seeking services. Screening will be conducted to determine the need for specialty mental health and/or substance use disorder services and the appropriate level of care. 1
C L-8.301 Service Availability for Roucine Conditions Page 2 of 5 1. Individuals and community members may access assistance after hours, weekends and holidays through the Department's toll-free 24/7 Access Line. 2 3.2. Alternatively, individuals or community members who first present themselves at a Department-operated or network provider program for mental health and/or substance use services will be met briefly by direct service staff to determine if the individual is in need of urgent or emergency services. 3 If no urgent or emergency condition is present, the individual will be connected with program staff for assessment, appropriate referral and authorization of services as indicated. 3.3. The following information will be gathered during the screening in order to determine an individual's needs and eligibility for a range of services provided through the Department and the community: 1. Determine whether the individual is currently experiencing a crisis due to a mental health and/or substance use disorder. If there are indications of possible danger to self, danger to others, or grave disability, staff will complete a risk assessment. 2. Determine Medi-Cal/Drug Medi-Cal eligibility, including limitations on benefits and county of responsibility. 3. Presenting mental health symptoms (i.e., type, frequency, duration, severity), level of functioning including employment (e.g., current and work history), as well as current social support systems such as family, roommates, friends, and organizations or groups. 4. Use/abuse of alcohol and other drugs, including duration of use, amount and frequency, last time used, type of substance, and treatment history. 5. Any current mental health and substance use treatment including currently prescribed psychiatric medications (i.e., name, dose, and prescribing physician for each) and other resources being utilized such as psychotherapy, in-home services, case management, etc. 6. History of psychiatric hospitalizations. If yes, obtain dates of hospitalizations and reasons for treatment. 7. Any significant physical illness or injury including head trauma or organic brain damage and other neurological disorders. 8. Access the Department's electronic health records system to determine previous contact with and/or services through the Department. 9. If the client is a child, or if there are children in the family, inquire about participation in Child Welfare Services (CWS) or Probation. 10. Identify other resources available, including health insurance through private or public sources. 2 Please refer to the Department's "24/7 Toll-free Access Line" 3
CL-8 301 Service Availability for Routine Conditions Page I 3 of 5 3.4. Following screening, the individual will be scheduled for an appointment with a provider for a complete assessment to determine medical necessity. The first appointment offered for assessment shall be within 10 calendar days following the initial request for service and screening in accordance with the Department's Network Adequacy Standards and Monitoring 4 policy. 3.5. Based on assessment, including review of American Society of Addiction Medicine (ASAM) criteria, staff will arrive at a determination of the optimum level of care and possible service delivery modalities determined to be medically necessary. 1. Psychiatrists and clinicians will be available for consultation to provide support in making decisions regarding an individual's symptom presentation and appropriate level of care and referrals. 3.6. Following the determination of appropriate service modalities and medical necessity, the best means of obtaining these services will be identified and referrals will be made. Decisions will be made within the parameters of resources and supports including Medi Cal eligibility, private insurance, and eligibility for other funded plans. 1. If staff determine the individual requires residential or withdrawal management services, staff will contact Access Line staff ta" request authorization and coordinate an appointment with a contracted residential provider. 3.7. Department programs and network providers will collaborate and work closely with care coordinators and case managers to ensure engagement, re-engagement and warm handoffs are present as the individual accesses services and proceeds through treatment. 4. MEDI-CAL BENEFICIARIES 4.1. In determining appropriate service modalities and referrals for Medi-Cal beneficiaries, and dependent on the individuals' unique needs, geographic location, and the current availability of services, the Department will complete one of the following: 1. In cases in which inpatient psychiatric services may be necessary, the procedures in the Department's Service Triage and Authorization for Urgent and Emergency Conditions 5 policy will be followed. 2. Referral and authorization to a Department network provider. 3. Referral and authorization to a Department-operated program. 4. Referral to the County of Responsibility if not Santa Barbara County. 4.2. If the beneficiary does not meet medical necessity criteria for Department services, referrals will be provided based on the client's residence and type of need. In addition, a Notice of Adverse Benefit Determination 6 (NOABD) will be sent to the beneficiary. 4 Please refer to the Department's "Network Adequacy Standards and Monitoring" 5 6 Please refer to the Department's "Notice of Adverse Benefit Determination"
CL-8.301: Service Availability for Routine Conditions Page 14 of 5 5. UNINSURED, PRIVATELY INSURED AND OTHER RESOURCES 5.1. In determining appropriate service modalities and referrals for individuals who are uninsured, privately insured, or reliant on other resources and funding for health care, and dependent on the individuals' unique needs, geographic location, and the current availability of services, the Department will complete one or more of the following: 1. In cases in which inpatient psychiatric services may be necessary, the procedures in the Department's Service Triage and Authorization for Urgent and Emergency Conditions 7 policy will be followed. 2. Referral to a Department program accepting clients on a sliding-scale basis. 3. Referral to community-based sliding scale clinics. 4. Referrals to education, housing, health, vocational rehabilitation, or regional center services within the community of residence as part of an overall plan of action. 5. Referral to Public Health clinics, low-cost or no-cost emergency or long- term housing programs, Homeless Outreach, or other community resources as identified. 6. CHOICE OF PROVIDER 6.1. Whenever a Medi-Cal beneficiary is referred to a Department network provider or program, the beneficiary's choice of provider, including culture-specific and other preferred providers, will be granted whenever feasible. When preferences cannot be met, every effort is made to assist the beneficiary in locating the most appropriate match to their requested preferences. 6.2. Beneficiaries who need or request providers with specific linguistic capabilities will be given referrals to providers who speak their preferred language or, ifthere are no available providers who speak their language, interpreters will be provided at no cost to the beneficiary. 7. DMC-ODS PRIORITY POPULATIONS 7.1. Department network providers shall admit on a priority basis in the following order: 1. Pregnant women who are using or abusing substances. 2. Women who are using or abusing substances who have dependent children. 3. Injecting drug users. 4. Substance abusers infected with HIV or who have tuberculosis. 5. All others. 7.2. Beneficiaries shall not be required to disclose whether they are HIV positive. 7
CL-8.301 Service Availability for Routine Conditions Page I 5 of 5 ASSISTANCE Suzanne Grimmesey, MFT, Chief Quality Care and Strategy Officer John Doyel, MA, LAADC, Division Chief of Alcohol and Drug Programs Melissa Wilkins, ADP Health Care Program Coordinator REFERENCE Code of Federal Regulations - Public Health Title 42, Section 438.10 California Department of Health Care Services (DHCS) Mental Health and Substance Use Disorder Services (MHSUDS) Information Notice NO.: 18-011, February 13, 2018. Federal Network Adequacy Standards for Mental Health Plans (MHPs) and Drug Medi-Ca/ Organized Delivery System (DMC-ODS) Pilot Counties. California Department of Health Care Services (DHCS) DMC-ODS Intergovernmental Agreement, Exhibit A, Attachment I California Code of Regulations - Rehabilitative and Development Services Title 9, Chapter 11, Sections 1810.405 and 1810.410 California Code of Regulations - Social Security Title 22, Section 51341.1 RELATED DOCUMENTS AND POLICIES 24/7 Toll-free Access Line Service Triage and Authorization for Urgent and Emergency Conditions Notice of Adverse Benefit Determination Network Adequacy Standards and Monitoring REVISION RECORD DATE VERSION REVISION DESCRIPTION 8/8/2018 2.0 Updated to reflect Drug Medi-Cal Delivery System requirements. Organized Culturally and Linguistically Competent Policies The Department of Behavioral Wellness is committed to the tenets of cultural competency and understands that culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse individuals. All policies and procedures are intended to reflect the integration of diversity and cultural literacy throughout the Department. To the fullest extent possible, information, services and treatments will be provided (in verbal and/or written form) in the individual's preferred language or mode of communication (i.e. assistive devices for blind/deaf).