UCARE MODEL OF CARE SUMMARY FOR MH-TCM (February 2009) The UCare Model of Care for Mental Health Targeted Case Management is designed to provide care for the child member and their families and adult members, working in conjunction with the counties and qualified, appropriate providers and agencies. Historically, care for members with mental health needs has been fragmented, with little or no coordination between health care, social service, and community providers. Up to this point, MH-TCM has been the responsibility of the Counties in Minnesota. Effective July 1, 2009, this responsibility will transition to the MCOs for members in the MHCP programs. I. Goals UCare s MH- TCM Model of Care has the following goals: Employ interventions to improve health outcomes and quality of life for members with mental health needs (SPMI or SED). Support adult access to medical, social, educational, vocational and other necessary services relating to member s mental health needs. Assist child and family to obtain needed mental health, social, educational, health, advocacy, transportation and legal services. II. Criteria for MH TCM The MH-TCM Model of Care follows the Minnesota Statutes defining criteria for members qualifying for targeted case management. Children with a diagnosis of SED (Severe Emotional Disturbance as defined in MN Statute 245.4871;subd 6) and adults with SPMI (Severe and Persistent Mental Illness as defined in MN Statute, section 245.462 subd 20) will be offered the choice of being assigned a case manager to work with them. SPMI: Severe and Persistent Mental Illness. (MN Statute, section 245.462 subd 20) means an adult who has a mental illness and meets at least one of the following criteria: 1. Has undergone two or more episodes of inpatient care for a mental illness within preceding 24 months. 2. Has experienced continued psychiatric hospitalization or residential treatment exceeding 6 months duration within preceding 12 months. 1
3. Been treated by a crisis team two or more times within the preceding 24 months. (Pending Federal approval). 4. The adult: A. Has a diagnosis of schizophrenia, bipolar disorder, major depression or borderline personality disorder. B. Indicates significant impairment in functioning, or C. Has a written opinion from a mental health professional within the last 3 years, stating the adult is reasonably likely to have future episodes requiring inpatient or residential treatment (of a frequency described in (1) or (2) above) unless ongoing CM (case management) or community support services are provided. 5. Has, within the last 3 years, been committed by a court as person who is mentally ill under Chapter 253B or commitment has been stayed or continued. 6. Eligible under above bullet points but specified time has expired or adult was eligible as child (sec 245.4871;subd 6) and as noted in 4C above. SED Severe Emotional Disturbance (MN Statute 245.4871;subd 6) a child who has an emotional disturbance and who meets one of the following criteria: 1. Has been admitted within the last three years or is at risk of being admitted to inpatient treatment or residential treatment for an emotional disturbance. 2. Is a Minnesota resident and is receiving inpatient treatment or residential treatment for an emotional disturbance through the Interstate Compact. 3. Has one of the following as determined by a mental health professional: A) Psychosis or clinical depression. B) Risk of harming self or others as a result of an emotional disturbance, or C) Psychopathological symptoms as a result of being a victim of physical/sexual abuse or of psychic trauma within past year, or D) As a result of an emotional disturbance has significantly impaired home, school, or community functioning lasting more than one year or in written opinion of mental health professional, presents substantial risk of lasting at least one year. 2
III. Case Management Process 1) Referral to County 2) County determines eligibility. 8) ICSP/IFCSP reviewed every 180 days 3) Diagnostic Assessment completed 7) Services delivered; CM monitoring 4) CM Functional Assessment completed 6) Create IFCSP/ICSP 5) Collect Data (as appropriate) A. Role of Case Manager: UCare supports CMS s definition of Case Management: Services that will assist the individuals eligible under the State plan in gaining access to needed medical, social, educational, and other services and to include the following: o Assessment. o Development of specific care plan. o Referral and related activities to obtain needed services. o Monitoring and follow up activities. 3
Appropriate identification of the member is a critically important success factor in achieving optimal clinical outcomes. The case management model must consist of a comprehensive assessment of the member to determine the need for any medical, educational, social or other services. It also includes development of a specific care plan based on information gathered during the assessment. The care plan must include goals and actions addressing the medical, educational, social and other services needed by the member. Appropriate and timely referral to assist the member in obtaining needed services and monitored follow up are required as well. B. Authorization/Notification: No changes will be made to this process. Utilization review will continue to be provided by BHP or MMSI. Providers must contact BHP or MMSI, as appropriate, for authorization/notification of services as outlined on UCare s provider web site page. NOTE: Counties are required to notify BHP or MMSI when a UCare member is assigned to a case manager and enrolled in TCM. C. What TCM does not include: Direct delivery: medical, educational, social or other services. Activities regarding administration of foster care programs. Activities paid for by third parties. Services that are components of other Medicaid services: ie, rehabilitation, therapy, diagnostic assessment, medication management. Treatment or therapy. Legal advocacy. Performing a diagnostic assessment. Administration, management, or monitoring medications. D. Case Load Average caseload of a CM providing services to children with SED shall not exceed the ratio of 15 clients to one FTE Case Manager.* Average caseload of a CM providing services to an adult with SPMI shall not exceed the ratio of 30 clients to one FTE case manager. * Caseload standards apply to counties and health plans. DHS will monitor caseload ratios. 4
*Reference: MN Rules 9520.0903, subd. 2 and 3; Bulletin #09-53-01, pg 12, #15 E. Documentation Requirements 1. Assessment Tools: Children s functional assessment CASII (recommended by DHS). This is currently the DHS recommended tool and has not been mandated by DHS at this time. Expectations are that it will be the required tool in the near future. Adult functional assessment DHS Functional Assessment (or current tool used by county). There is no DHS recommended tool at this time. 2. Plan of Care: Establish IFCSP/ICSP. Goals and actions (medical, educational, social, other). Participation. Monitor effectiveness of plan. 3. Case Notes: Documentation of face to face visit every 30 days or as stated in contract agreement. Document progress or lack of progress toward goals. Document review of IFCSP/ICSP every 180 days (or more often if requested). IV. Case Management Staff and Supervisor Qualifications: UCare follows the requirements set forth by DHS for staff conducting case management for the MH TCM member population. Services must be provided consistent with Rule 79, parts 9520.0900 to 9520.0926, MN Statutes sections 245.487 to 245.4889 and 256B.0625 subd 20 and 245.461 to 245.486. A. Child Case Manager: Except as provided in subpart 3, a case manager providing case management services to a child with SED must have a bachelor's degree in one of the behavioral sciences or related fields from an accredited college or university and have at 5
least 2,000 hours of supervised experience in the delivery of mental health services to children with emotional disturbance, be skilled in identifying and appraising the child's needs, be skilled in setting and monitoring appropriate service outcomes, and be knowledgeable about local community resources and how to use the resources for the benefit of the child and the child's family. A person from any professional discipline that is part of the local system of care serving children or who is employed by or under contract to the local agency is eligible to serve as a case manager for children with SED if the person meets the above qualifications. B. Adult Case Manager. Except as provided in subpart 3, a case manager providing case management services to an adult with SPMI must have a bachelor's degree in one of the behavioral sciences or related fields from an accredited college or university and have at least 2,000 hours of supervised experience in the delivery of services to adults with mental illness, must be skilled in the process of identifying and assessing a wide range of client needs, must be skilled in setting and monitoring appropriate service outcomes, and must be knowledgeable about local community resources and how to use those resources for the benefit of the adult with serious and persistent mental illness. C. Supervision: Case Manager. If the mental health professional is providing clinical supervision of a case manager who provides case management services to children, the mental health professional must be qualified as specified in Minnesota Statutes, section 245.4871, subdivision 27, and must be skilled and knowledgeable about children with emotional disturbance. The mental health professional providing the clinical supervision must document the clinical supervision in the client's record. 1. Clinical supervision is not required for a case manager who is qualified as a mental health professional. 2. Case managers who are not qualified as mental health professionals under Minnesota Statutes, section 245.4871, subdivision 27, for services to children with emotional disturbance or under Minnesota Statutes, section 245.462, subdivision 18, for services to adults with mental illness, and who have at least 2,000 hours of supervised experience in the delivery of mental health services, as appropriate, to 6
children or adults must meet in person with a mental health professional at least once each month to obtain clinical supervision. 3. Case managers who have a bachelor's degree in one of the behavioral sciences or a related field from an accredited college or university but who do not have 2,000 hours of supervised experience in the delivery of mental health services as appropriate to children with emotional disturbance or adults with serious and persistent mental illness, must receive clinical supervision regarding individual service delivery from a mental health professional at least once each week until the requirement of 2,000 hours of experience is met. V. Conclusion: UCare will establish a collaborative relationship with counties and providers. This will include monitoring and reporting of progress toward established outcome measures. We support the need for better coordination and case management of physical health, mental health and social services and to work collaboratively with the counties and other providers to improve outcomes for this population. VI. References: Minnesota Statutes, section 256B.0625, subd. 20 Comprehensive Adult and Children s Mental Health Acts, Minnesota Statutes, sections 245.4711-245.4887. Minnesota Statutes, sections 245.487-245.4889. Minnesota Statutes, sections 245.461-245.468. Minnesota Statutes, sections 245.4682. Minnesota Statutes, sections 245.486. Minnesota Rules, parts 9520.0900-9520.0926. Minnesota Statute, chapter 253B (Minnesota Commitment and Treatment Act) Minnesota Statute, section 245.462 Adult Mental Health Services: Activities that are coordinated with the community support services program and are designed to help adults with serious and persistent mental illness in gaining access to needed medical, social, educational, vocational and other necessary services as they relate to the client s mental health needs. Includes: Functional assessment. ICSP (Individual community support plan). 7
Referring/assisting member to obtain needed mental health and other services. Coordination of services. Monitoring the delivery of services. Minnesota Statute, section 245.4871 Child Mental Health Services: Activities that are coordinated with the family community support services and are designed to help the child with severe emotional disturbance and the child s family obtain needed mental health, social, educational, health, vocational, recreational services and related services in the areas of volunteer services, advocacy, transportation and legal services. Includes: Assistance in obtaining a comprehensive diagnostic assessment as needed. Developing a functional assessment. Developing an IFCSP (Individual family community support plan). Assistance to child and family to obtain needed services by coordination with other agencies. Assure continuity of care. Assess/reassess delivery, appropriateness and effectiveness of services over time. Minnesota Rule: 9520.0900-9520.0926 * Also referred to as RULE 79: establishes standards and procedures for providing mental health CM services. Must be read in conjunction with applicable Minnesota statutes. *Also reference: MHCP Provider Manual (Chapter 16) @ http://www.dhs.state.mn.us/id_058037. 8