Mental Health Medi-Cal Specialty Mental Health Services (SMHS): … · personality disorder Suicidal/Homicidal preoccupation with plan or behavior in past year Transitional Age Youth

San Francisco Mental Health Plan (SFMHP)

Behavioral Health Services (BHS)

BHS Quality Management

Clinical Documentation Improvement Program (CDIP)

January 2018staff contact: [email protected]

Mental Health Medi-Cal Specialty

Mental Health Services (SMHS):

Private Provider Network (PPN)

Outpatient (Non-Hospital)

Documentation Training

Mins Item Objective

10 Overview: Mental Health Medi-Cal • Logic and frame of MH M-Cal Insurance

10 Medical Necessity • Required elements and clinical pathways

10 Assessment • WHAT is the problem?

10 Treatment Plan of Care (TPOC) • WHY does problem exist?

10 Services & Progress Notes • HOW to address problem

10Case Conceptualization &

Efficiency Strategies• Improve your documentation

2

Agenda/Objectives

MENTAL HEALTH MEDI-CAL

“Medi-Cal Insurance”

Physical Health

Medi-Cal

Mental Health

Medi-Cal

Drug Medi-Cal/

ODS

San

Francisco

Health

Plan

Blue

Cross

Partner.

Plan

BHS

(County

MHP)

BHS

(County

SUD Plan)

• Physical health care

• Mild/Moderate MH care

• Autism Spectrum/BHT

• SMHS

• Moderate

to severe

MH care

• SUD

Treatment

Services

San Francisco Mental Health Plan (January 2018) 3


San Francisco Mental Health Plan (January 2018)

• Example Algorithm: Health vs. Mental Health Plan Services (for adult client)

List A List B List C

Persistent symptoms & impairments after

2 recent medication trials

Multiple co-morbid health and mental

health conditions

Behavior problems (aggressive/self-

destructive/assaultive/extreme isolation)

Excessive ED visits or 911 calls

Bipolar disorder

Trauma/recent loss/significant life

stressors

Depressive symptoms

Anxiety symptoms

Homelessness/housing instability

resulting from mental health condition

ADHD symptoms

Lack of diagnostic clarity

2 or more psychiatric hospitalizations

within 12

Functionally significant, non-substance

induced paranoia, delusions,

hallucinations, mania,

dissociative symptoms, depression,

personality disorder

Suicidal/Homicidal preoccupation with

plan or behavior in past year

Transitional Age Youth with prodromal

psychotic symptoms

Eating disorder with medical

complications (with medical condition

being treated by Health Plan)

Substance use

disorder not

responding to

SBI (screening

& brief

intervention at

primary care)


San Francisco Mental Health Plan (January 2018)

• Example Algorithm: Health vs. Mental Health Plan Services for adult client

List A List B List C

Persistent symptoms & impairments after

2 recent medication trials

Multiple co-morbid health and mental

health conditions

Behavior problems (aggressive/self-

destructive/assaultive/extreme isolation)

Excessive ED visits or 911 calls

Bipolar disorder

Trauma/recent loss/significant life

stressors

Depressive symptoms

Anxiety symptoms

Homelessness/housing instability

resulting from mental health condition

ADHD symptoms

Lack of diagnostic clarity

2 or more psychiatric hospitalizations

within 12

Functionally significant, non-substance

induced paranoia, delusions,

hallucinations, mania,

dissociative symptoms, depression,

personality disorder

Suicidal/Homicidal preoccupation with

plan or behavior in past year

Transitional Age Youth with prodromal

psychotic symptoms

Eating disorder with medical

complications (with medical condition

being treated by Health Plan)

Substance use

disorder not

responding to

SBI (screening

& brief

intervention at

primary care)

Specialty Mental Health (County MH Plan)

>4 from list A or >1 from list B

Non-Specialty Mental Health (Health Plan/Beacon):

<3 from list A and 0 from list B

Screening forms (0-4yrs; 5-17yrs; >18yrs) posted to SF Health Plan website

http://www.sfhp.org/providers/provider-resources/mental-health-resources/


Area Clinic Model Rehabilitation Model

Definition from

Federal Social

Security Act

§1905(a)(9): “Clinic services [are

those] furnished by or under the

direction of a physician, without

regard to whether the clinic itself is

administered by a physician,

including such services furnished

outside the clinic by clinic personnel

to an eligible individual who does

not reside in a permanent dwelling

or does not have a fixed home or

mailing address”

§1905(a)(13): “Other diagnostic, screening,

preventive, and rehabilitative services,

including any medical or remedial services

(provided in a facility, a home, or other setting)

recommended by a physician or other

licensed practitioner of the healing arts

[LPHA] within the scope of their practice under

State law, for the maximum reduction of

physical or mental disability and restoration

of an individual to the best possible functional

level”

Treatment

ModelMedical model Recovery model

Focus Stabilization Active treatment and participation

Locations Clinic-based Community-based

Type of StaffLicensed; higher degree

professionals

Professionals, mental health technicians and

peer specialists

Organizational

ModelOrganized clinics

Organizations that provide one or more

covered servicesSan Francisco Mental Health Plan (January 2018) 6


Provide Treatment

Interventions

MH

Medi-Cal

Conduct assessment Create treatment plan Provide interventionsClinical

Practice

“The Golden Thread” of Clinical Practice & Mental Health Medi-Cal

Establish Diagnosis &

Functional

Impairments

Create Treatment

Plan/Client Plan

“what is the problem?” “why problem exists” “how to address it”


Medical Necessity for SMHS

• Four Required Elements of Medical Necessity:

1. Included mental health diagnosis

2. Functional impairments (from dx)

3. Treatment interventions (for impairments)

4. Not responsive to physical health care treatment


Medical Necessity for SMHS

• Four Required Elements of Medical Necessity:

9

Medical Necessity: DIAGNOSIS

• Diagnosis (Element #1):

• Your assessment will describe the symptoms, behaviors and differential diagnosis using DSM.

• Primary MH Dx = Mental Health Medi-Cal

• Primary SUD Dx = Drug Medi-Cal/ODS

• Primary Medical Dx = Physical Health M-Cal

• MH problems 2 to Medical = as above

• Mild/Moderate MH problems = as above

• Tip: SMHS = Special Diagnosis—one that appears on the DHCS list (not just any old dx!)


Medical Necessity: DIAGNOSIS

• Diagnosis (Element #1):


Medical Necessity: IMPAIRMENTS

• Functional Impairments (Element #2):

• Functional Impairments as a result of the qualifying diagnosis:

• Symptoms = behavioral expressions/actions associated with the disorder

• Distractibility in client with ADHD diagnosis…

• Impairments = the consequences/outcomes that ensue for the individual as a result of these behaviors

• …can’t pay attention and failing at work

• …can’t stop interrupting and loses friends 12



• Functional Impairments as a result of the qualifying diagnosis:

• A current significant impairment in an important area of life functioning

• A probability of significant deterioration

• A probability that the child will not progress developmentally as individually appropriate

• If full-scope Medi-Cal, under age of 21 years and has a condition as a result of the mental disorder that SMHS can correct or ameliorate

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• Functional Impairments in an Important Area of Life Functioning:

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Life Functioning Domains to Explore

• Living situation

• Daily activities and functioning

• Family relations

• Social relations

• Finances

• Legal and safety issues

• Work and school

• Health

• Cultural components

• Potential for exploitationSource: BHS Documentation

Manual (2005 Ed & 2012 Eds.)



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Medical Necessity: INTERVENTIONS

• Interventions (Element #3):

• The focus of the proposed/actual interventions must address the functional impairment identified as a result of the qualifying mental health diagnosis:

• Focus = functional impairments

• Proposed interventions = creating Client Plan

• Actual interventions = creating Progress Notes

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Medical Necessity: INTERVENTIONS

• Interventions (Element #3):

• Expectation that proposed/actual interventions must do one of the following:

• Significantly diminish the functional impairment;

• Prevent significant deterioration in functioning

• Allow for a child to progress developmentally as individually appropriate

• Correct/ameliorate the condition for FS-MC, <21 years

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Medical Necessity: TIP

• Tip: line up your impairments/interventions… these are clinical stories!

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Functional Impairment Pathway Treatment Interventions Pathway

#1: Client has current significant

impairments…

…my interventions will significantly diminish

impairments

#2: Client has probability of significant

deterioration…

…my interventions will prevent significant

deterioration in functioning

#3: Child client has probability of child not

progressing developmentally…

…interventions allow the child to progress

developmentally

#4: Child client has Full-scope Medi-Cal +

<21yrs + a condition that SMHS can correct

or ameliorate…

…interventions correct or ameliorate the

condition

Medical Necessity: NOT PHSYICAL

• Not Responsive to Physical Health Care-Based Treatment (Element #4):

• The condition/impairment (that exists as a result of a covered diagnosis) would not be responsive to physical health care based treatment.

• Examples:

• Depression related to a thyroid condition.

• Traumatic brain injury that leads to violent behaviors.

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Assessment

• Assessment:

• “Assessment” in SMHS: Words Matter!!

• Service: an ACTIVITY to evaluate current mental, emotional, behavioral health (includes MSE, analysis of clinical history, relevant cultural issues, diagnosis);

• Document: a FORM you fill out annually, or when there is a change in the client’s impairments;

• Phase of Treatment: a PERIOD OF TIME when you are determining medical necessity for services.


Assessment SERVICE

• Assessment Service:

• Only bill assessment if you are doing an assessment!

• a service activity designed to evaluate the current status of a beneficiary’s mental, emotional, or behavioral health. Assessment includes but is not limited to one or more of the following: mental status determination, analysis of the beneficiary’s clinical history; analysis of relevant cultural issues and history; diagnosis; and the use of testing procedures (CCR Title 9, Section 1810.204)


Assessment FORM

• Assessment Form:

• Fill out completely and SIGN/DATE THE FORM!


Assessment PHASE

• Assessment Phase:

• Your authorization determines the “phase” of assessment!

• Remember-the purpose of an assessment is to determine medical necessity for Specialty Mental Health Services.

• SIGN AND DATE THE DOCUMENT—IT’S NOT FINAL UNTIL YOU DO!

• Never copy/paste documents!!!San Francisco Mental Health Plan (January 2018) 23

Treatment Plan of Care (TPOC)

• The TPOC/Client Plan is IMPORTANT:

• The Client Plan must address the mental health needs identified in the current assessment (The Golden Thread…assessmentimpairments).

• The Client Plan must have Goals/Objectives that address the functional impairments (The Golden Thread…assessmentimpairments).

• The Client Plan must be updated when there are significant changes in the client’s condition (at a minimum, updated Annually).




• Document your attempt to get the client’s signature on the Client Plan—get that signature!

• The Client Plan is officially “finalized” when the requiredstaff signature (YOURS) is in place and dated.

• You must finalize the Client Plan before providing treatment services. In other words, you cannot bill “planned services” until the Client Plan is finalized—you will only be able to bill “Plan Development” services.





Services: Case Conference (Plan Development)

• Case Conference as Plan Development:

• DHCS has clarified (and BHS/SFMHP has implemented) “case conference” may be billed as plan development, as follows.

• CASE CONFERENCE = discussions between direct service providers and other significant support persons or entities involved in the care of the beneficiary. Could be similar or comparable to a multi-disciplinary team meeting;

• CASE CONFERENCE AS PLAN

DEVELOPMENT = If the case conference concerns the development of a treatment plan for a beneficiary, the conference could be claimed as Plan Development


Services: THERAPY

• Therapy: definition for Medi-Cal

• “Therapy” means a service activity that is a

therapeutic intervention that focuses primarily on

symptom reduction as a means to improve

functional impairments. Therapy may be delivered

to an individual or group of beneficiaries and may

include family therapy at which the beneficiary is

present.


Services: THERAPY

• Therapy: example for Medi-Cal

“Conducted individual therapy session to address

Client Plan Objective (‘meet more people so I can find

someone to date’).”

“Implemented behavioral rehearsal intervention with

client. Client was able to introduce himself and ask an

appropriate open-ended question with minimal

prompts from therapist.”

“Mental status exam: no change in thought content/

processes from initial meeting. No suicidality observed.”29

Services: PROGRESS NOTE P-I-R-P

• P-I-R-P Format:

• Problem = Problem from the treatment plan you are focusing on

• Intervention = Your interventions and activities that address functional impairments (i.e., significantly diminishing impairments/preventing significant decline)

• Response = Client’s response to your interventions (with details about how/why the interventions work, changes that are needed, etc.)

• Plan = You and the client’s next steps to achieve treatment goals

30

Services: PROGRESS NOTE FORM

• P-I-R-P Format

31

Case Conceptualization Method

Most problematic SYMPTOMS of diagnosis…

+

Functioning DOMAINS impacted by symptoms…

+

HYPOTHESIS of “how this works”…

32

#1

#2

#3


• Client meets criteria for GAD…

• most problematic symptoms are inability to control worry, difficulty concentrating and irritability

• Client has significant impairment in work domain…

• Due to worry, poor concentration and irritability, the client’s work attendance and work performance have declined significantly

• Client’s impairments can be improved…

• Client is unable to recognize/manage symptoms and becomes overwhelmed—this leads him to miss work excessively (calls out sick 1-2x/week), make mistakes at work (“zones out and gets lost” over worry for 30mins) and is at risk for losing his job (“I’ve had 3 verbal warnings”)

33

#2

#3

#1


• Client’s impairments can be improved…

• Client is unable to recognize/manage symptoms and becomes overwhelmed—this leads him to miss work excessively (calls out sick 1-2x/week), make mistakes at work (“zones out and gets lost” over worry for 30mins) and is at risk for losing his job (“I’ve had 3 verbal warnings”).

• DBT interventions can help client make sense of symptoms (psychoeducation), manage symptoms (mindfulness, distress tolerance) and reduce work impairments (implement calming skills and tools in vivo).

• Weekly therapy sessions will initially focus on reducing client’s level of stress and psychoeducation. Teaching and practicing skills will occur in session, at home & at work.

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#3

IMPLEMENTING Documentation

• Efficiency Tips…

• Stop copying/pasting and start answering the question being asked (read the prompts on the forms and directly address them);

• Don’t leave blanks on the forms (e.g., not yet assessed, insufficient information to rate, etc.);

• Prioritize Assessment items (presenting problem; relevant conditions; risks/strengths; mental status exam; case formulation);

• Easy access to source documents (documentation manual, instructions for forms)

35

PRACTICE!

• Do what the auditors do!

• Assessment & Diagnosis criteria (behaviorally specific; included list; sign the form);

• Impairment criteria (current significant/risk of significant decline);

• Intervention Criteria (reducing the current significant/ preventing risk of significant decline);

• Not Physical Health Care-Based Treatment criteria

36

Treatment Authorization Request!

• Initial Treatment Authorization Request (TAR)

• Required prior to delivery of service!

37


• Initial Treatment Authorization Request (TAR)

• Required prior to delivery of service!

38


• ONGOING TAR—Medical Necessity Attestation for Continued Treatment

39



• Attestation: confirm that all of the elements of medical necessity

• Level of Care Confirmation: the client’s mental health needs may/may not be met at this level—we need to check!

40



41



• Client’s progress: significant impairments are being significantly reduced? Prevention of significant decline in functioning?

• Rationale for Continued Treatment: What is the current status of the client? What are the functional impairments? What are the mental health needs!

42

Wrapping Up

• Questions and Thoughts?

• Resources:

• “Must haves” are 2017 Documentation Manual, Desk Reference & guidance from authorizing body (BHAC, FCMH, FMP, etc.)

• BHS URL: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/

• CDIP URL: https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSQualityMgmt.asp

• BHS Compliance: [email protected];

• BHS Documentation Improvement: [email protected]

https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/

https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSQualityMgmt.asp

mailto:[email protected]

mailto:[email protected]

Documents

Mental Health Medi-Cal Specialty Mental Health Services (SMHS): … · personality disorder Suicidal/Homicidal preoccupation with plan or behavior in past year Transitional Age Youth