AGREEMENT BETWEEN ORIGINAL NORTH SOUND REGIONAL SUPPORT NETWORK AND.- CPC FAIRFAX HOSPITAL 1 PURPOSE OF AGREEMENT The purpose of this Agreement is to define responsibilities and establish procedures between North Sound Regional Support Network (NSRSN) and CPC Fairfax Hospital to facilitate admission, treatment and discharge planning, and to ensure continuity of care. DESCRIPTION OF RELATED RESPONSIBILITIES CPC Fairfax Hospital is a licensed psychiatric inpatient facility in King County under contract with the State of Washington for Medicaid beds and complies with WAC 275-54,275-55 and 275-57 and REC 71.05, 71.34 and 71.24., and is Certified to provide psychiatric inpatient community hospital services for: [X ]children (0-1 7), [X ]adults (1 8-59), [ ]aging adults (60+). NSRSN is the regional public mental health authority providing outpatient services in Island, San Juan, Skagit, Snohomish and Whatcom Counties. Effective March 1, 1998 the NSRSN became a Prepaid Health Plan responsible at full financial risk for the management of all medically necessary psychiatric inpatient community hospital services for eligible persons (children, adults and aging adults). NSRSN and CPC Fairfax Hospital agree to work cooperatively to ensure quality service to the inpatient population as set forth in Memorandum #: 98-61 (or current MAA Memorandum) and the NSRSN Level of Care Manual. Specifically, both parties understand and agree to the following: DEFINITIONS Services: Acute inpatient psychiatric hospitalization at Contractor facility. Eligible Persons: 1. DSHS Medical Assistance clients (Title XIX andfor state program recipients) residing in the NSRSN Service Area (Island, San Juan, Skagit, Snohomish and Whatcom Counties) or intending to reside within NSRSN 'Service Area upon discharge from services; or 2. People detained by NSRSN-designated County Designated Mental Health Professionals (CDMHP's). Individuals who have insurance or private payment resources, or who do not require referral to NSRSN are not included in this Agreement. Medically Necessary: as defined in Memorandum 98-61 (or the current MAA Memorandum), incorporated herein by reference and appended to this Agreement as Attachment No. 1. SERVICE RECIPIENT CHOICE It is the mutual understanding of both parties that eligible persons should have choice in all services to the fullest extent possible. Both parties agree to involve the service recipient and hislher family in admission, treatment and discharge planning whenever possible. Page 1 of 6
CONFIDENTIALITY Both parties shall protect all information, records and data collected from unauthorized disclosure in accordance with all applicable federal and state laws, rules and regulations, including but not limited to 42 CFR 431.300 through 431.307; RCWs 70.02, 71.05, and 71.34; and for eligible persons receiving alcohol and drug abuse services in accordance with 42 CFR Part 2. GOALS 1. The goals for authorizing voluntary inpatient psychiatric services are to: Ensure that appropriate alternatives to inpatient hospitalization are made available whenever possible; Ensure that inpatient psychiatric hospitalization services, when medically necessary, are easily accessible; Ensure that the service plans for hospitalized patients employ the highest standards of care and active treatment toward the most efficient use of hospital days; Ensure that active treatment and discharge planning helps to reduce overall lengths of stay; Ensure that persons who meet specific statutory requirements, and have indicated they are willing to use appropriate alternatives, and are considered to be "good faith" voluntary admissions, are hospitalized and receive safe and appropriate care. The Hospital shall document when voluntary admissions under this scenario do not occur (i.e., an individual is detained) and why. Ensure continuity of care through the active participation of the community mental health system, inpatient facilities, patients and families. 2. The goals of involuntary treatment services are to: Ensure that appropriate alternatives to involuntary inpatient hospitalization are made available whenever possible; Ensure that persons who meet specific statutory requirements and are unwillin~lunable to use appropriate alternatives, are detained for involuntary hospitalization and receive safe and appropriate care. To be detained, persons must, as a result of a mental disorder, present a likelihood of serious harm to selflothers or property of others, or be gravely disabled. GOOD FAITH Both parties: 1. Wish to acknowledge good faith in the implementation of this Agreement; 2. Understand that continued development and modification of the Agreement may occur; 3. Agree to participate in regular meetings to facilitate a good working relationship and solve any problems identified by CPC Fairfax Hospital, NSRSN, or NSRSN's provider network. Page 2 of 6
ADMISSION AND AUTHORIZATION Both parties acknowledge that NSRSN is the single, centralized regional mental health authority for ~edicaid and state program recipients residing within NSRSN, and as such is responsible for managing resources and care for service recipients of both inpatient and outpatient services. Services to eligible persons must be pre-authorized by NSRSN (or its designee) pursuant to Memorandum #: 98-61 MAA (or the current MAA Memorandum), incorporated herein by reference and appended to this Agreement as Attachment 1 and in accordance with NSRSN authorization procedures, incorporated herein by reference and appended to this Agreement as Attachment 2. CPC Fairfax Hospital shall Request authorization/admission from NSRSN (or its designee) for all people who are not referred by IVSRSN (or its designee). The request for authorization shall be made to the appropriate NSRSN (or its designee) contact person (see Attachment 1, Memorandum #: 98-61 MAA and Attachment 2) prior to admission. Request authorization/admission from NSRSN (or its designee) when any resident of the NSRSN service area receiving services makes application for determination of Medical Assistance eligibility. Admit involuntary patients detained by NSRSN-designated CDMHPs who are- deemed to meet admission criteria. Admit voluntary patients certified by NSRSN County-Designated Mental Health Professionals (CDMHPs) or other NSRSN authority for whom services are "medically necessary", and who are deemed to meet admission criteria. NSRSN (or Desiqnee) shall Perform the following inpatient psychiatric management services: 1. Prior authorization of voluntary and involuntary inpatient admissions; 2. Provide payment authorization number for involuntary inpatient admissions; 3. Perform Length of Stay Review of voluntary hospitalization stays past the 75'h percentile of average LOS (PAS guidelines); 4. Prior authorization of voluntary inpatient extensions; 5. Perform retrospective review of initial and continued stay for those patients later determined to be eligible for Medicaid; 6. Document and notify certification decisions; 7. Facilitate access to community mental health providers for discharge and planning, and 8. Data collection and reporting to the State. 9. Review and approve length of stay extensions for any person in an involuntary commitment who remains more than 20 days in an acute care facility. 10. Provide a standard admission packet for all NSRSN consumers at the time of admission or as soon thereafter as possible. Information shall include the following: "Certification for Admission to Psychiatric Inpatient Care"form (including an Authorization Number); [this document shall be completed and forwarded to CPC Fairfax Hospital for ALL Medicaid Eligible Certifications, regardless of their NSRSN consumer status.] Current service plan, Recent progress notes, including medical notes, Relevant psychosocial, drug/alcohol and psychiatric history, including current diagnosis and medications; Case Manager's the Director of Case Management's name and telephone number; and Involuntary Treatment documentation (if any). Page 3 of 6
'TREATMENT PLANNING Both NSRSN and CPC Fairfax Hospital shall ensure that the inpatient and community plans of care are integrated. Furthermore, CPC Fairfax Hospital1 shall: Notify NSRSN (or its designee) with suggested times for treatment planning meetings. Accept and review input from NSRSN (or its designee) and incorporate appropriate recommendations in treatment plans. Provide the services of mental health specialists (WAC 275-57-320) for inpatients identified as members of a special population, specifically children, older adults, ethnic minorities and people with a disability (developmental or deaf). Permit and facilitate the participation of NSRSN (or its designee) in consultations with the mental health specialists. Provide NSRSN (or its designee) full access to NSRSN eligible client charts in order for NSRSN to perform concurrent, urgent and retrospective reviews. NSRSN (or its designee) shall: Participate with CPC Fairfax Hospital in the development and implementation of the inpatient plan of care either in person when possible or by speaker telephone. CONSULTATION CPC Fairfax Hospital shall provide access to hospital staff for consultation concerning hospital and community treatment and discharge planning. NSRSN (or designee) shall provide access to community staff for consultation concerning hospital and community treatment and discharge planning. INVOLUNTARY TREATMENT NSRSN-designated CDMHPs will cooperate fully with CPC Fairfax Hospital and the presiding County Superior Court. NSRSN (or its designee) will be available in person or by telephone for testimony in court hearings. CHANGE IN STATUS CPC Fairfax Hospital shall notify NSRSN (or its designee) of the following changes in service recipient status as soon as possible, not to exceed 24 hours from the time such change is known to CPC Fairfax Hospital: 1. Unauthorized leave; 2. Conversion from involuntary to voluntary status under chapters 71.05 or 71.34 RCW; 3. Conversion from voluntary to involuntary status under chapters 71.05 or 71.34 RCW; 4. Application for determination of Medical Assistance eligibility; 5. Change in the principal ICD-9-CM diagnosis code to a mental disorder; or 6. Hospital identifies need for extraordinary psychiatric service not usually covered by MAA (e.g., electroconvulsive therapy.) Page 4 of 6
DISCHARGE NSRSN (or its designee) and CPC Fairfax Hospital shall jointly develop and implement an appropriate and timely discharge plan. Furthermore, CPC Fairfax Hospital shall: 1. Inform NSRSN (or its designee) of any patient discharged prior to the development of a discharge plan (e.g., AMA discharge.) 2. Inform NSRSN (or its designee) of any delayed discharge due to off lack of appropriate community placement. 3. Provide NSRSN (or its designee) at the time of discharge (or as soon thereafter as possible, not to exceed 7 calendar days) a standard discharge packet which includes: Current treatment plan Psychiatric evaluation, Psychosocial assessment, Physical examination, Relevant lab results, rug and alcohol information, Discharge diagnosis, Current medication(s) Discharge plan Recommendations for ongoing care Documents such as discharge summaries and court orders that are not available at the time of release will be mailed as soon as they are available. 4. Complete and send NSRSN the RSN Psychiatric Inpatient Data Form no later than seven (7) days after the patient discharge (see Attachment 2). NSRSN (or designee) shall: 1. Be responsible for transportation when more appropriate or more cost-effective transportation is not available. 2. Provide appropriate and timely community mental health supports and services to eligible persons upon discharge from inpatient services. RESOURCE MANAGEMENT / UTILIZATION REVIEW / CONCURRENT REVIEW NSRSN (or designee) shall: Provide resource management of community inpatient services in accordance with Resource Management of Acute lnpatient Care, Exhibit of the Interagency Agreement between State of Washington, Department of Social and Health Services and North Sound Regional Support Network, or any future contract (appended to this Agreement as Attachment No. 3) Conduct concurrent review of length of stay in accordance with applicable standards for hospitals paid on a Ratio of Cost to Charges (RCC) basis. Authorize reimbursement in accordance with Memorandum #: 98-61 by means of Pre- and Post- Admission Certification, Length of Stay Extension for Voluntary Care, Other Length of Stay Page 5 of 6
Extensions, Billing Procedures, Planning Requirements, and Information Requirements (see Attachment 2). DISPUTE RESOLUTION PROCEDURES Any dispute that arises from this Agreement may be resolved in accordance with the principle of resolution at the lowest level. NS%N and CPC Fairfax Hospital shall each identify an individual who will have the authority to be final arbiter to resolve disputes. The dispute shall not impact the orderly treatment of service recipients. AMENDMENTS TO THIS AGREEMENT Either party may submit to the other party an amendment to this ~~rebment. No amendment shall be effective unless both parties sign such amendment. EFFECTIVE TERM he parties shall conform to this Agreement until either party serves written notice to the other party of their withdrawal. The Agreement shall terminate immediately upon service of such written notice. The parties hereto have caused this Agreement to be executed in duplicate original as of the date of the last party to sign below: FOR NORTH SOUND REGIONAL SUPPORT NETWORK FOR CPC FAIRFAX HOSPITAL Executive Director Date Dhte ' Page 6 of 6