Intensive In-Home Services (IIHS): Aligning Care Efficiencies with Effective Treatment BHM Healthcare Solutions 2013 1
Presentation Objectives Attendees will have a thorough understanding of Intensive In-Home Services (IIHS) from an authorization perspective Attendees will gain an understanding of the importance of Medical Necessity Criteria as it applies to IIHS Attendees will learn key questions to ask through the authorization process BHM Healthcare Solutions 2013 2
Understanding Medical Necessity Criteria (MNC) According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance) Medical necessity is individual but some generally accepted components are: Intended to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a diagnosable condition that threatens life, causes pain or suffering, or results in illness of infirmity Treatment is expected to improve the condition or levels of functions in relationship to the presenting diagnosis A clear cut definition does not exist. BHM Healthcare Solutions 2013 3
Understanding Medical Necessity Criteria (MNC) According to a presentation by NC Department of Health and Human Services (Division of Medical Assistance) Medical Necessity Essential and consistent with nationally acceptable standard of practice Reflective of a level of service that is safe, where not equally effective, more conservative, and less costly treatment is available Not primarily intended for the convenience of the person, family, caretaker, or provider. It is not based upon availability of provider. Empathy does not equal medical necessity. Is individualized, specific and consistent with the symptoms and diagnosis Is not in excess of the person s needs BHM Healthcare Solutions 2013 4
Understanding Medical Necessity Criteria (MNC) General Criteria Covered Medicaid shall cover procedures, products, and services related to this policy when they are medically necessary, and: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary s needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary s caretaker, or the provider. BHM Healthcare Solutions 2013 5
The Intensive In-Home Service is a team approach designed to address the identified needs of children and adolescents who, due to serious and chronic symptoms of an emotional, behavioral, or substance use disorder, are unable to remain stable in the community without intensive interventions. This service may only be provided to members through age 20. Understanding Intensive In- Home Services (IIHS) BHM Healthcare Solutions 2013 6
Understanding Intensive In- Home Services (IIHS) This medically necessary service directly addresses the beneficiary s mental health or substance-related diagnostic and clinical needs. The needs are evidenced by the presence of a diagnosable mental, behavioral, or emotional disturbance (as defined by DSM-IV-TR and its successors), with documentation of symptoms and effects reflected in the Comprehensive Clinical Assessment and the PCP. This team provides a variety of clinical rehabilitative interventions available 24 hours per day, 7 days per week, and 365 days per year. BHM Healthcare Solutions 2013 7
Understanding Intensive In- Home Services (IIHS) This is a time-limited, intensive child and family intervention based on the clinical needs of the beneficiary. The service is intended to accomplish the following: reduce presenting psychiatric or substance abuse symptoms, provide first responder intervention to diffuse current crisis, ensure linkage to community services and resources, and prevent out of home placement for the beneficiary. BHM Healthcare Solutions 2013 8
Understanding Intensive In- Home Services (IIHS) IIHS are authorized for one individual child in the family. The parent or caregiver must be an active participant in the treatment. The team provides individualized services that are developed in full partnership with the family. Effective engagement, including cultural sensitivity, is essential in providing services in the family s living environment. Services are generally more intensive at the beginning of treatment and decrease over time as the beneficiary s skills develop. BHM Healthcare Solutions 2013 9
Understanding Intensive In- Home Services (IIHS) IIHS are delivered to children and adolescents, primarily in their living environments, with a family focus, and include but are not limited to the following interventions as clinically indicated: Individual and family therapy Substance abuse treatment interventions Developing and implementing a home-based behavioral support plan with the beneficiary and the beneficiary s caregivers Psycho-education imparts information about the beneficiary s diagnosis, condition, and treatment to the beneficiary, family, caregivers, or other individuals involved with the beneficiary s care. BHM Healthcare Solutions 2013 10
Understanding Intensive Case Management Linkage and referral to paid and natural supports Monitoring and follow up Planning Arrangements for psychological and psychiatric evaluations Assessment Intensive Case Management includes the following: Crisis management BHM Healthcare Solutions 2013 11
First Responder Crisis Response for IIHS The IIHS Team shall provide first responder crisis response, as indicated in the Person Centered Plan (PCP), 24 hours a day, 7 days a week, and 365 days a year to members of this service. In partnership with the beneficiary, the beneficiary s family, and the legally responsible person, as appropriate, the Licensed or QP is responsible for convening the Child and Family Team, which is the vehicle for the person centered planning (PCP) process. BHM Healthcare Solutions 2013 12
First Responder Crisis Response for IIHS The Licensed or QP is responsible for monitoring and documenting the status of the beneficiary s progress and the effectiveness of the strategies and interventions outlined in the PCP. The Licensed or QP consults with identified medical (such as primary care and psychiatric) and non-medical providers (e.g., the county department of social services [DSS], school, the Department of Juvenile Justice and Delinquency Prevention [DJJDP]), engages community and natural supports, and includes their input in the person-centered planning process. BHM Healthcare Solutions 2013 13
First Responder Crisis Response for IIHS Cont. IIHS also includes telephone time with the individual beneficiary and the beneficiary s family or caregivers, as well as collateral contact with persons who assist the beneficiary in meeting the beneficiary s rehabilitation goals specified in the PCP. IIHS includes participation and ongoing clinical involvement with the Child and Family Team and meetings for the planning, development, implementation, and revision of the beneficiary s PCP. BHM Healthcare Solutions 2013 14
Expectation of Services Program Requirements for IIHS members, all aspects of the delivery of this service occurring per date of service will equal one per diem event of a two hour minimum It is the expectation that service frequency will decrease over time: at least 12 face-to-face contacts per beneficiary are required in the first month, and at least 6 face-to face contacts per beneficiary per month are required in the second and third months of IIHS. The IIHS varies in intensity to meet the changing needs of members, families, and caregivers; to assist them in the home and community settings; and to provide a sufficient level of service as an alternative to the beneficiary s need for a higher level of care. BHM Healthcare Solutions 2013 15
Expectation of Services Cont. Services are delivered face-to-face with the beneficiary, family, and caregivers and in locations outside the agency s facility. Each provider agency will assess and document at least annually the aggregate services delivered at each site using both of the following quality assurance benchmarks: At least 60% of the contacts shall occur face-to-face with the beneficiary, family, and caregivers. The remaining units may be either telephone or collateral contacts. At least 60% of staff time shall be spent working outside of the agency s facility, with or on behalf of the members. BHM Healthcare Solutions 2013 16
Managing Care: IIHS Eligibility Criteria Some aspects of eligibility criteria such as diagnosis, frequency and severity of symptoms, and whether or not outpatient treatment has been attempted only need to be reviewed once at the beginning of the episode of care Other aspects of eligibility will need to be reviewed for each authorization, and additional authorizations including but not limited to: Risk of out of home placement Unmanageable in a traditional setting The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the beneficiary s PCP BHM Healthcare Solutions 2013 17
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for initial authorization, but does not need to be reviewed for Continued Stay or additional authorizations There is an Axis I or II MH/SA diagnosis (as defined by the DSM-IV-TR or its successors), other than a sole diagnosis of intellectual or developmental disability. Yes; or No BHM Healthcare Solutions 2013 18
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for initial authorization, but does not need to be reviewed for Continued Stay or additional authorizations Is the current diagnosis supported with respect to the frequency and severity of symptoms? Yes; or No BHM Healthcare Solutions 2013 19
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for initial authorization, but does not need to be reviewed for Continued Stay or additional authorizations Has outpatient treatment been attempted? Yes; or No BHM Healthcare Solutions 2013 20
IIHS Eligibility Criteria Key Questions In regard to whether outpatient treatment has been attempted, the following questions should be asked: If so, what happened? Is it well documented? Did parents or other caregivers participate with that treatment? If it was not attempted, why not? Is that well documented? Is the rationale included in the assessment a component of the referral for IIH services? Could it be attempted now? Under what circumstances? BHM Healthcare Solutions 2013 21
Managing Care: IIHS Eligibility Criteria Cont. The beneficiary has current or past history of symptoms or behaviors indicating the need for a crisis intervention as evidenced by suicidal or homicidal ideation, physical aggression toward others, self-injurious behavior, serious risk taking behavior (running away, sexual aggression, sexually reactive behavior, or substance use). For each authorization crisis situation information needs to be evaluated to determine if the consumer is still in a crisis situation (new and ongoing cases) BHM Healthcare Solutions 2013 22
IIHS Eligibility Criteria Key Questions In regard to whether the consumer is in a crisis situation, the following questions should be asked: Is it truly a crisis or just an ongoing issue with longer term problematic behavior? Why is it a crisis now? For new cases, what was happening 6 months ago when it was not a crisis? Is this youth demonstrating signs of a character disorder? (behaviors do have consequences) What techniques have been used in the past to deal with the symptoms? BHM Healthcare Solutions 2013 23
IIHS Eligibility Criteria Key Questions (Cont.) In regard to whether the consumer is in a crisis situation, the following questions should be asked: How have the caregivers typically responded? Is there a way to modify that? Has this member ever been inpatient? Is that well documented? Has this member been arrested? Is that well documented? Is the overall treatment history well documented to support the need to call this a crisis? BHM Healthcare Solutions 2013 24
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for each authorization The beneficiary s symptoms and behaviors are unmanageable at home, school, or in other community settings due to the deterioration of the beneficiary s mental health or substance abuse condition, requiring intensive, coordinated clinical interventions. Yes; or No BHM Healthcare Solutions 2013 25
IIHS Eligibility Criteria Key Questions In regard to unmanageable behavior, the following questions should be asked: Why now? What has caused this to occur? What will it take to make it stop? Could other less intrusive services work? How do we know that? Is this about poor supervision, or is it typical adolescent behavior that does not require this level of intervention. BHM Healthcare Solutions 2013 26
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for each authorization The beneficiary is at imminent risk of out-of-home placement based on the beneficiary s current mental health or substance abuse clinical symptomatology, or is currently in an out- of-home placement and a return home is imminent. Yes; or No BHM Healthcare Solutions 2013 27
Understanding Imminent Risk What is imminent risk? 1. likely to occur at any moment; impending: Her death is imminent. This does require that something be done. However, it does not have to be Intensive In Home Services. It really depends on what the clinical presentation shows, what is the diagnosis, the history of treatment, the parent or caregivers willingness to work on the issues etc. BHM Healthcare Solutions 2013 28
IIHS Eligibility Criteria: Understanding Alternatives There is no evidence to support that alternative interventions would be equally or more effective, based on North Carolina community practice standards (Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Society of Addiction Medicine). This is especially important when determining when to authorize this. There are many other services that could be attempted that many times were not. Let s discuss services that have been authorized in the past where other services may have helped. BHM Healthcare Solutions 2013 29
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for each authorization after initial authorization Continued Service Criteria The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the beneficiary s PCP; or the beneficiary continues to be at risk for out-of-home placement, based on current clinical assessment, history, and the tenuous nature of the functional gains. Yes; or No BHM Healthcare Solutions 2013 30
Managing Care: IIHS Eligibility Criteria Additionally, one of the following applies (this is applicable to each authorization): A. The beneficiary has achieved current PCP goals, and additional goals are indicated as evidenced by documented symptoms. B. The beneficiary is making satisfactory progress toward meeting goals and there is documentation that supports that continuation of this service will be effective in addressing the goals outlined in the PCP. C. The beneficiary is making some progress, but the specific interventions in the PCP need to be modified so that greater gains, which are consistent with the beneficiary's premorbid level of functioning, are possible. D. The beneficiary fails to make progress, or demonstrates regression, in meeting goals through the interventions outlined in the PCP. The beneficiary s diagnosis should be reassessed to identify any unrecognized cooccurring disorders, and interventions or treatment recommendations should be revised based on the findings. This includes consideration of alternative or additional services. BHM Healthcare Solutions 2013 31
Managing Care: IIHS Eligibility Criteria This criteria applies for everyone who receives this service This needs to be reviewed for each authorization after initial authorization The desired outcome has occurred? Yes; or No BHM Healthcare Solutions 2013 32
IIHS Eligibility Criteria The consumer discharge date, and discharge plan are crucial elements in mapping out the care plan Reviewers should view the discharge plan as the end goal of treatment and evaluate whether the level of care prescribed is furthering the discharge goal according to the timeline ALWAYS ASK, What is the estimated discharge date and plan! BHM Healthcare Solutions 2013 33
Discharge Criteria Any one of the following applies: A. The beneficiary has achieved goals and is no longer in need of IIH services. B. The beneficiary s level of functioning has improved with respect to the goals outlined in the PCP, inclusive of a transition plan to step down to a lower level of care. Any one of the following applies C. The beneficiary is not making progress or is regressing, and all reasonable strategies and interventions have been exhausted, indicating a need for more intensive services. D. The beneficiary or legally responsible person no longer wishes to receive IIH services. E. The beneficiary, based on presentation and failure to show improvement despite modifications in the PCP, requires a more appropriate best practice treatment modality based on North Carolina community practice standards (for example, National Institute of Drug Abuse, American Psychiatric Association). BHM Healthcare Solutions 2013 34
Question and Answer Session Other resources: Medicaid Clinical Decision Support Tools http://www.ncdhhs.gov/dma/mp/index.htm EPSDT Information http://www.ncdhhs.gov/dma/epsdt/index.htm IPRS Clinical Decision Support Tools http://www.ncdhhs.gov/mhddsas/providers/servicedefs/index.htm BHM Healthcare Solutions 2013 35
More resources Best Practice Clinical Practice Guidelines Links can be found on Eastpointe website under provider community/ Medicaid Utilization Review/ top three links on left hand side BHM Healthcare Solutions 2013 36
Contact information Presented by: Lynnette Gordon, LPC, LCAS UM director Eastpointe LME/MCO lgordon@eastpointe.net 910-298-7036 BHM Healthcare Solutions 2013 37