Embed Size (px)
Citation preview
STRTP and EPSDT©
Program Application and Documentation Standards
Developed by:Lisa Scott-Lee, [email protected] Santa Clara County Department of Mental Health
1
Special Thanks to…
Nancy Nation, LCSW, Mental Health Program Specialist, Behavioral Health Services
Chiaki Nomoto, LMFT, Learning Partnership Training Manager
2
Presentation Overview/Outline
EPSDT Defined: Requirements & Criteria
STRTP Defined and how intersects with EPSDT
Practical Application in Documenting STRTP Services
Documentation Samples: Do’s and Don’ts tied to STRTP Service
What is EPSDT?
Early and Periodic Screening, Diagnosis and Treatment
Defined under California Code of Regulations (CCR), Title 9, §1810.215 as a “Supplemental Mental Health Service”
Mental Health Service under WIC 5601 is any service directed toward early intervention in, or alleviation or prevention of, mental disorder, including, but not limited to, diagnosis, evaluation, treatment…. socialization, case management……..information, referral, consultation, and community services.
Claimable under Medi-Cal (Medicaid)
4
How Does EPSDT impact Medical Necessity?
EPSDT broadens the definition to allow intervention
to “correct or ameliorate” a mental health condition and does not restrict services to
“Severely Emotionally Disturbed” (SED) child/youth, therefore expanding the target population served (larger net, less restrictive) Medical Necessity threshold is lowered…
5
How does one “define” Medical Necessity?
Two Medical Necessity Features:
• An “Included or Covered” Primary Diagnostic Features based on the Diagnostic Statistical Manual of Mental Disorders (DSM) and International Classification of Disorders (ICD)
• Functional Impairment impacting quality life that requires intervention or assistance
6
For more Information see
Santa Clara QI 03-22-2018\Clinical Practice Guidelines.pdf
Why Medical Necessity matters to STRTPs?
Progressive change for youth placed out of home
Transforming traditional Group Homes conceptually, both in definition and approach
Focusing on Recovery and Strength-based
SHORT-TERM is the operative term and intent
7
Short Term Residential Therapeutic Programs (STRTP)
a residential facility operated by a public agency or private organization, licensed by CDSS pursuant to HSC §1562.01
provides an integrated program of specialized and intensive care and supervision, services and supports, treatment, and short-term 24-hour care and supervision to children.
care and supervision provided by a STRTP shall be nonmedical, except as otherwise permitted by law.
Private STRTP shall be organized and operated on a nonprofit basis.
8
What to assess?
Santa Clara CountyInitial Mental Health Assessment
(Completed by STRTP Clinician)
9
Stakeholders Defined
Clinician/Family Specialist/Mental Health Rehab Specialist
Significant Support Persons
Community/Resources
The Child/Youth!
10
How does one “define” Comprehensive Assessment?
Assessmentis defined by CCR Title 9 §1810.204 as:
…a service activity designed to evaluate the current status of a beneficiary's mental, emotional, or behavioral health.
11
Assessmentas defined by CCR Title 9 §1810.204 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.
12
Other types of Assessments conducted by SCC Mental Health Services
1. Initial Mental Health Assessment (remember, out of MHP County clients must be assessed within 4-business days of referral receipt!)
2. Mental Health Assessment Update
3. Unicare/HealthLink
Can you think of other Types of Assessments or Evaluations?
13
Number One Audit Exception on Assessments? Leaving _______....BLANKS Potential Errors of Omission! Need evidence of asking or query,
even if no info available:
Example: “Katrina’s developmental history is
unknown according to the Social Worker”
14
What to assess?
Assessment Guidance(SCC BHSD Practice Standards
Manual, Page 13-22)
15
Sources of Information
• Child/Youth• Family/Guardian/Caregiver* • Social Services*• Criminal justice*• School*• Other*
*NOTE: These sources may include “Significant Support Persons”
16
Significant Support Person Defined
CCR, Title 9, §1810.246.1
"Significant support person" means persons, in the opinion of the beneficiary or the person providing services,
who have or could have a significant role in the successful outcome of treatment,
including but not limited to the parents or legal guardian of a beneficiary who is a minor, the legal representative of a beneficiary who is not a minor*, a person living in the same household as the beneficiary, the beneficiary's spouse, and relatives of the beneficiary.
17
Support Systems: Your potential “Collateral” contacts
Significant community support(extended family, school teacher, neighbor,
place of worship, civic, social)
NOTE: Potential “Significant Support Person” in Treatment Plan
18
Clinical Formulation
Licensed Practitioner of the Healing Arts (LPHA)
Hypothesized reason/context for the presenting problems;
19
Whose the client?
The child/youth, however…
Can include in clinical formulation something about the family/caregiver home that contributes to youth’s significant impairment (resulting in the STRTP placement) with goal to ↓ functional impairment
↑ family reunification or a stable forever home (stability and permanency)
Examples? 20
Current Mental Health Presentation
Critical!!Include:• First rule-out “Medical”
explanation for the targeted behavior• Current symptoms• Current and Persistent behaviors• family response to current situation
including stressors
• Most importantly, MATCHES & supports Diagnosis (for medical necessity)!
21
Mental Health History
AlsoInclude:• Symptom onset, duration, severity…• Use of current DSM/ICD descriptors • Previous Treatment in chronological
order
22
Child/Youth/Family Strengths
e.g., motivation, insight, support of family/community, special talents, abilities, and interest, etc.
These insights can reinforce goals and objectives and be part of successful Treatment Plan!
23
Cultural factors which may influence presenting problems
May include ethnicity, race, language, immigration, level of acculturation or assimilation, religion, spiritual practice, sexual orientation, caregiver socioeconomic status, living environment.
24
Strength based does not mean…
Ignoring the elephant in the room; you need to describe the negative behaviors to be addressed, and
Then, incorporate youth’s strengths/resilience and social supports to address targeted behaviors
25
Psychosocial History
Should Include:• Prenatal (FAS, low birth weights)• Developmental milestones • Family History (financial,
relationship issues, living arrangements, mental health/SA)
• Education… Individualized Educational Plan
26
Medical History & Substance History in the Assessments
Tells us about the youth’s history, not the parents/caregivers!
Parent’s and Caregiver’s history is in “psycho social” section!
27
Medical History
Past/current illnesses and medical conditions include previous hospitalization): List.
Alternative healing practice/date (e.g., acupuncture, hypnosis, etc.): Date, Provider/Type, Reasons for Treatment, Outcome (was it helpful and why): Complete.
Current medication/previous medication(include all prescribed and over-the counter medications and holistic/alternative remedies): Name, Dosage Date Started, Effectiveness/Side Effects.
Allergies: List.
Primary Physician: name and phone number.
Date of last physical /dental exam?28
Primary Care History Requirement
• STRTP ICC Coordinator assurance of link to a Primary Care Physician for an assessment for any medical issues, etc… must be documented!
• Include Dental Care & Issues too!
29
Assessment: Don’t forget…
Consider Behaviors Impact on functioning(include impact on self-care, home, school, and community. Note whether the impairments are due to symptoms/behavior of the included DSM-5 /ICD 10 Diagnosis): Describe.
Precipitating events and other significant life events leading to current situation (e.g., divorce, losses, moves, school changes, financial difficulties): Describe.
30
Substance/Alcohol Use
Specify type-including tobacco and caffeine, frequency and amount, and level of impairment [e.g., missing work/school, law enforcement or incarceration, family’s level of concern and attempts to intervene]) The new SUT Manual
substance Use SUTS-documentation-manual SCC 2017.docx
31
Purpose of Risk Assessments
• Rule-out and reduce the likelihood or chance of potential risk of current or imminent harm.
32
Day to Day Risk Assessments
Inflicting Harm or being harmed by others (Bully vs. Bullied?)
Gang/Criminal involvement
High Risk Behaviors (Suicidality, Runaways, Hyper-sexualized, poor choices)
Assessing Grave Disability
33
Assessing Grave Disability (Secondary to a Mental Disorder)
Different for Children and Youth vs. adults:
Not based on inability to provide “food, shelter, or clothing secondary to a Mental Disorder”
Instead it is the inability to “utilize” food, shelter or clothing you provide them…
34
Self-destructive/suicidal behavior/danger to self
Include:• Level of impairment [e.g., ideation,
plan, threats, attempts/gestures, crisis services, hospitalization])
• Current Risk• STRTP ICC Coordinator ensures Safety
Plan within STRTP and partner providers
35
Assessing Risk for Self-Harm
36
o Social Media Sites or Postso Self-Isolation
Assessing Risk for Harm to Others
37
Victimization: Bully or Victim?
Charting Aggressive behavior
• Document [school detentions and suspension, law enforcement, crisis services, and hospitalization?]):
• Charting precipitating events any precursors?
• INTERVENTION/ACTIONS• Plans to avoid reoccurrence?
38
STRTP: more at the moment intervention skill-buildingIHBS focus on individual proactive skill-buildingICC Coordinator: Ensure addressed in all plans and settings
At Risk of Higher Level of Service?
Meeting Criteria for more intensive services or
Therapeutic Behavioral Services (TBS)
Crisis Stabilization or Inpatient Care?
Referral to Santa Clara County Mental Health Call Center (800) 704-0900
39
Mental Status Examination by the STRTP’s Licensed Practitioner of the Healing Arts (LPHA)
Mental Status Exam
ThoughtProcesses
Hallucinations Delusions
Memory & Intellectual Functioning
Appearance Motor
Function
Mood & Affect
Sensorium Orientation
Speech
Insight Judgment
40
Diagnosis
Made ONLY by a Licensed Practitioner of the Healing Arts (LPHA)
- Physician [MD/DO] - Psychologists [PhD/PsyD/EdD],- Licensed or Associate Clinical Social Workers
[LCSW] - Licensed or Associate Marriage, Family & Child
Therapist [MFT] - Licensed Professional Clinical Counselor [LPCC]- Registered Psychiatric Nurses (CNS, NP)
41
What is an “Included PRIMARY Diagnosis” for Medical Necessity?
• “Covered/Included Primary Diagnosis” is defined by California Code of Regulations, Title 9, Article 2, section 1830.205
IS IN REGULATORY TRANSITION!!!
• Must still have a PRIMARY reason/necessity for behavioral health treatment intervention
• DHCS directs MHP to use DSM-5 since the ICD-10 […]does not contain information needed to determine diagnosis. (MHSUDS INFORMATION NOTICE NO.: 16-051)
• Both the ICD-10 and the corresponding DSM-5 diagnosis codes should be indicated in the beneficiary’s clinical record
42
Included/Covered Primary Diagnosis that Meets Medical Necessity
Reference:
MHSUDS Information Notice No: 17-004E (10/13/2017) International Classification of Diseases, Tenth Revision (ICD-10) Included Sets
Specialty Mental Health Outpatient Services (Enclosure 2) – ICD-10 Covered Diagnosis Table
43
44
• Use the individual ICD-10 codes for these diagnoses• Use the diagnostic criteria in DSM-IV to establish these
diagnoses since no comparable criteria are available in DSM-5
o Autistic Disorder (F84.0) o Rett’s Disorder (F84.2) o Childhood Disintegrative Disorder (F84.3) o Asperger’s Disorder (F84.5) o Other Pervasive Developmental Disorder (F84.8)o Pervasive Developmental Disorder Unspecified (F84.9)
DHCS Directive on DSM-5 and Autism Spectrum for LPHAs
Exception to the crosswalk tables for Autism SpectrumDisorder & Childhood Disintegrative Disorder and Rett’s Disorder
STRTP LPHA: Where do you get these Diagnoses?
Being mindful of source diagnosis: Who made it, its relevancy, does it meet “Medical Necessity”?
Primary or Targeted Diagnosis must always match and substantiate child/youth symptoms and behaviors (especially if “multiple diagnoses” are listed)
45
What is meant by“Functional Impairment”?
A significant impairment in an important area of life functioning (use developmental, social impairments to justify)
A probability of significant deterioration in an important area of life functioning (identify)
A probability a child/youth will not progress developmentally as individually appropriate.(use developmental milestones as measure)
46
Probability of significant deterioration in an important area of life functioning.
Without intervention child/youth will deteriorate:
• At STRTP Home• At School• In Community
(i.e., loss of functioning in the above spheres)
47
Probability a child/youth will not progress developmentally as individually appropriate.
Lack of Progression OR Regression
• 10 year old still OR starts sucking thumb
• 8 year old cannot feed or dress self (secondary to a mental disorder)
• 14 year old (without a medical condition) is incontinent
• services provided will reduce impairment, restore functioning, or prevent deterioration in an important area of life functioning, as outlined in the client plan
48
Important: include behaviors that are a barrier to reunification and impact permanency/stability in any Assessment Leads to a STRTP home goal that
addresses targeted behavior and significant impairment of the youth in the Treatment Plan
Will assist STRTP staff in targeting behaviors that are a barrier to homebound permanency
Provides Focuses supportive documentation/charting
49
Medical Necessity Necessities
Document the presenting behaviors and symptoms
STRTP Clinician always document the Primary, “Included/Covered Diagnosis” in the first listing position
STRTP staff chart interventions with examples of functional impairment in the home
Direct Treatment Goals in Plan
Mirror medical necessity in Progress Notes
50
Pain-Point: Santa Clara QI states insufficient documentation that interventions support Medical Necessity
What is the
51
?
Assess Symptoms &
Behavior
Support DSM Diagnosis & Functional
Impairment
Transformational Care Plan (TCP)
address symptoms & Behaviors
Progress notes interventions
address Symptoms &
Behaviors in TCP
Support Medical Necessity
Assessment Updates
IHBS, ICC and STRTP services requires evidence of reassessing the strengths and needs of children and youth, and their families, at least every 90-days, for the purpose of determining if ICC and/or IHBS should be added or modified
What does the child/youth need, RIGHT NOW?
STRTP clinician can always update the Assessment at anytime, needs the STRTP direct staff input!
52
No Billing of Planned Services
Assessment and Care Plan must be completed PRIOR to the billing of most Services (including Rehab and Collateral), except for Psychiatric Emergency (Crisis Intervention), or urgent Med Support, Assessment and Plan Development!
53
No Billing !
=No Assessment No Care Plan
Be S-M-A-R-T!
Santa Clara County Guidance also requires Client/Care Plans be SMART(s),• Specific, • Measurable, • Attainable, • Realistic & • Time-Framed & Signed!
54
For the STRTP LPHA: Transformational Care Plans measurable and quantifiable! (The 5 W’s *and the two H’s)
Why are the services needed? Who is providing the services? What type of services are being provided? Where are the services provided? When and/or how often will you see child
and the significant support persons?And, How are you measuring improvement? How does the client and caregivers know
there’s improvement?55
Client/Care Plan Requirements (Santa Clara’s MHP Contract with the State DHCS)
Client Plan must include, but are not limited to, reference to child/youth’s participation and
agreement in the body of the plan, A signature (by the child/youth) signature &
Caregiver on the plan, or description of the youth and Caregiver’s
participation and agreement in progress notes. must be updated when there was a significant
change in youth’s condition
56
Transformational Care Planning (TCP) in Treatment Plans
GoalsObjectivesDesired Results
57
58
TCP Planning Means:
• Person-centered• Family driven• Principles of : inclusion hope wellness resiliency and recovery.
A collaborative process between an individual/family and his/her service provider(s). (See example)
CCR Title 9, Focus of Intervention must address the condition/functional impairment (i.e., DSM Diagnosis)
The expectation is that the proposed intervention will:
1. Significantly diminish/reduce the functional impairment
2. Prevent significant deterioration in an important area of life functioning
3. Allow the child/youth to progress developmentally as individually appropriate
59
What are the Requirements of Plans of Care?
Client Treatment Plan shall:
Have specific observable and/or specific quantifiable goals
Identify the proposed type(s) of intervention
Have a proposed duration of intervention(s)
STRTP Interventions has to support TCP Plan!
60
Treatment Care Plan Requirements cont.
When the client and/or caregiver’s signature is required on the TCP Client Plan of Care; if the client and/or caregiver refuses or is unavailable for signature, you MUST include a written explanation of the refusal or unavailability…and persistence, if unavailable.
61
Client Plan Requirements cont.
• Intensive Care Coordinator (ICC) is responsible for assuring that TCP Plans are distributed to all Behavioral Health Care Providers/collaborators for coordinated care for an individual client.
• The MHP shall offer a copy of the TCP Treatment Plan to the client upon request…so ask! Document in Progress Notes if offered, and declined.
62
Client Plan Requirements cont.
Timeliness/Frequency of Client Plan
State requires most services to be updated at least annually
For IHBS, ICC and TFC require evidence that it has a procedure for reassessing the strengths and needs of children and youth, and their families, at least every 90-days, for the purpose of determining if ICC and/or IHBS should be added or modified.
The MHP shall establish standardsfor timeliness and frequency for theindividual elements of the client plan.
63
64
Initial – 60 days (except for cases open/closed less than 60 days)
Transfers – 60 days, i.e., a transfer from one program to another, even within the same agency
Change/Addition of services – requires new Treatment Plan or Interim Update Form to be completed prior to start of new services
What is it for your STRTP programs? Semi-annual? Annually?
Santa Clara County MHP Care Plan Timelines
Red Flag Reminders
No Late Treatment Plans Focus of Intervention consistent with
behaviors identified & match Diagnosis Specific observable/quantifiable goals Must be signed or co-signed by LPHA Evidence of client or caregiver
participation and agreement (signature) Parenting Interventions support TCP
Treatment Plan that focus on child’s symptom reduction or child’s mental health
Billing
Putting our Knowledge to Use
Vignettes:• A “Vignette” is a brief incident or scenario that
allows us to practice with what we just learned and apply our knowledge in a practical, hands-on exercise.
• By design, vignettes requires you to add logical or additional details and assumptions that support your hypothesis or conjecture…
66
Vignette Analysis: Use the following guide with the following Vignette
STRTP Clinician: What to rule out first and Possible Primary Diagnosis?
ANYONE: What are the functional impairment?
ANYONE: Does Miyuen meet Medical Necessity? Why?
ANYONE: Recommendations for an intervention to (diminish, prevent, or allow developmental progress, one, two, all?)
67
Vignette
Miyuen is a 8 y.o. Asian-American girl who presents as fidgeting, squirming, reported to constantly leave her seat during class; she often runs about or climbs on everything; Miyuen has difficulty playing or engaging in leisure activities quietly and is often “on the go” or often acts as if “driven by a motor”; Miyuen talks incessantly, has difficulty waiting her turn and often interrupts or intrudes upon others personal space.
Miyuen is failing in most of her classes, and fights with her STRTP peers who find her intrusive and rude.
68
69
STRTP, IHBS, ICC and EPSDT Crosswalks
A Reference Guide Primary focus on assessment,
plan development, rehab progress notes and case management
Red Flag Crosswalk for denied claims
PROGRESS NOTES
If it isn’t documented….
71
Progress Notes
Document all contacts & interventions Due within 5 business days of service Late entry, include the actual date of
service. Sign and put date you wrote the late entry in progress note.
Not all actions will be claimable, but all observations are helpful insights and explanations.
72
PROGRESS NOTES REQUIREMENTS
One progress note per service Date of service (month, day, year) Duration of service in minutes Place of Service (home, office, community) Type of service, e.g., Rehab, CM, Plan Dev. Signed, County title/credential, include license/registration #, date of signature Legibility All progress notes document services provided in the client’s preferred language.
73
Progress note and billing must match or risk disallowance.
Santa Clara BH Progress Note Considerations…PIR + P
P = Presenting problem (why is client there) I = Interventions (what did you provide; therapeutic techniques). Does this service: • Reduce Impairment? • Restore Functioning? or • Prevent significant deterioration in an important area of life functioning as outlined in the client plan? R = Response (of client) +P = Plan (what is your next step or follow-up*Assessment, Plan Development and Case Management do not have to follow PIR format.
74
STRTP Service activities, mayinclude:
Mental Health Services (Assessments, Plan Development TCP, Rehab, Collateral, Therapy)
Medication Support Crisis Intervention Case Management/Brokerage
through Coordination of services Intensive Care Coordination (ICC) Intensive Home-Based Services
(IHBS)75
Santa Clara County Authorized Services for STRTPS
Service Percentage of Total Services
Average Hours per Month per Child
Mental Health Serv ices (Assessment, TCP Plan Development, Rehab, Collateral, Therapy)
45% 15.75 Hours
Intensive Home-Based Services (IHBS) 20% 6.775 Hours
Intensive Care Coordination (ICC) 15% 5.25 Hours
Case Management/Brokerage 10% 3.5 Hours
Medication Support 5% 1.75 Hours
Crisis Intervention 5% 1.75 Hours
76
Review: Assessment Notes
9 CCR §1810.204
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.
77
CPT staff use Full Assess: 90791 or Brief Assess: 96127HCPC staff use H0031
78
STRTP Assessment Note Example 1
03-02-20 85 mins. OFFICEP: Jorge striking others when frustrated or angry.I: I summarized and assessed the presenting problem, evaluating and reviewing the behavioral triggers, and impact of consequences of the behavior. R: Reviewed with collateral stakeholders (teacher, social worker, staff) their perception of problem behaviors, completed intake assessment. P: Plan is to review different support programs and work with Jorge, ICC Coordinator and partner providers in developing TCP Plan of Care. ----Joe Staff, LCSW, 1234
79
STRTP Assessment Note Example 2
03-08-20 104 mins STRTP HOMEP: Jorge striking others when frustrated or angry.I: Completed initial assessment. Obtained copy of court ordered consent for services. Met with identified significant support person, “Maria”, a family specialist. Assessed Jorge’s presenting problems and behaviors, conducted a functional analysis of the problem behaviors, Jorge’s “likes and dislikes”; asked Maria to complete standardized assessment measures of Jorge’s behavior. P: Plan to review assessment findings with Maria and care plan partners to complete the TCP Plan of Care next week. -----------Joe Staff, LCSW 1234
Importance of including the STRTP Client goal in the Assessment
STRTP goals address behaviors and significant impairment of the client in the Transformational Care Plan
Will assist in STRTP staff to focus ACTION/INTERVENTIONS on specific goal
Helps with supportive documentation (Progress Notes) as well!
80
Review: Plan Development
9 CCR §1810.232
a service activity that consists of development of client plans, approval of client plans, and/or monitoring of a beneficiary's progress.
81
HCPCS: H0032 Plan Development
82
STRTP Plan Development Example
05-21-20 44 mins. OFFICEP: Jorge striking others when frustrated or angry.I: Spoke with Jorge’s social worker about behavior goals. Jorge hits others when angry and does not get his way. Will work on STRTP home plan for Jorge to use his words when angry. Goal is to set initial lower threshold and reinforcement for Jorge to use words when angered with reward of computer time (see TCP Plan dated 05-21-20). P: Follow-up plan is for ICC Coordinator to connect with community partners next week to implement TCP plan in school and community---Joe Staff, LCSW 1234
Plan Development H0032
Review: Case Management/Brokerage
9 CCR §1810.249
services that assist a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative, or other community services. The service activities may include, but are not limited to, communication, coordination, and referral; monitoring service delivery to ensure beneficiary access to service and the service delivery system; monitoring of the beneficiary's progress; placement services; and plan development.
83
Linkage/Brokerage/Consultation T1017
84
Case Management/Brokerage Activity and Linkage Example
06-01-20 28 mins. OFFICEContacted Jorge’s mental health coach about her follow-through with referral to community organizations to help Jorge redirect his free time to increase his socialization skills and use as a positive reinforcer. Jane states she will use referral list provided. Plan is to follow-up on this linkage next week.- Joe Staff, LCSW 1234
85
Case Management/Brokerage Consultation Example
06-12-20 164 mins. SchoolP: Miyeun easily distracted and disruptive in SchoolI: Met with Ms. Jones, (school teacher) about Miyeun’s school performance and classroom behavior that create barriers to her education. P: Plan is to coordinate a plan with classroom school aide, at school on possible ways to redirect Miyeun to increase her attention and decrease distraction and disruption in the classroom. Next monitor follow-up on 06-21-20---Manuel Staff, MFT, 1234
86
Case Management/Brokerage Rehab/Non-Licensed Staff Example
06-05-2020 33 mins. STRTP HomeSpoke with STRTP staff regarding Jorge’s current placement and STRTP home behavior. Plan is to work with residential counselors on possible behavioral interventions and redirects with positive reinforcers identified by Jorge’s significant support persons at the STRTP home.---------------Joe Staff, MHRS, BA
Review: Rehabilitation (Rehab)9 CCR §1810.243
a service activity which includes, but is not limited to assistance in improving, maintaining, or restoring a beneficiary's or group of beneficiaries' functional skills, daily living skills,social and leisure skills, grooming and personal hygiene skills, meal preparation skills, and support resources; and/or medication education.
87
H2015 All staff can claim for Rehab
88
STRTP Rehabilitation (Rehab) Individual Note Example
06-25-20 122 mins. STRTP HomeP: Miyeun often interrupts or intrudes upon others personal space.I: Today Miyeun and I practiced a skill-building exercise on how to physically distance herself and respect others personal space. R: Miyeun was able to use her extended arm to use as a measure of distance, progressing to her “estimating” without her arm extended. Miyeun said she would try this with peers. P: Plan is to continue with skill-building exercises to increase confidence in maintaining appropriate space from others. Next meetup 07-03-20. --------Jane STRTP, MHRS
Review: Individual Therapy (LPHA)
9 CCR §1810.250a 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.
89
90
Individual Therapy Example06-06-2020 62 mins STRTP HOME Service Provided in Spanish. P: Jamie resorts to hitting peers when angryI: Jamie and I worked with hand-puppets to role play how to say “No” and avoid peer conflicts. Practiced rewarding positive behaviors and ignoring behaviors with the “Stop, Think, Say “No” and Look for alternatives. Jamie used his Iron Man puppet to strike "sister puppet" explaining his sister always "takes my stuff and breaks it!" Reinforced Jamie to use his "words" and seek help from trusted adults.R: Jamie was able to role play alternative positive outcomes with the puppets. P: Plan is to continue work on reinforcing Jamie verbalizing his frustration-----Joe Staff, LCSW, 1234
Review: Crisis Intervention
9 CCR §1810.209
a service, lasting less than 24 hours, to or on behalf of a beneficiary for a condition that requires more timely response than a regularly scheduled visit. Service activities include but are not limited to one or more of the following: assessment, collateral and therapy….
91
CPT staff claim 90839 first 60 mins. Add-on code: 90840 each additional 30 mins HCPC User: H2011
92
Crisis Intervention Example
09-02-20 59 mins. OFFICEReceived urgent phone call from STRTP staff, outside of prescheduled appointment, secondary to the Shona "blowing" out. Shona is at immediate risk of Crisis hospitalization due to threats of property destruction, self-harm and harm to others. Worked with STRTP staff on how to redirect Shona and model calm behavior. Briefly practiced interventions. Intervention proved effective; STRTP staff able to deescalate Shona. Plan is to have follow-up at the STRTP home tomorrow for in person assessment and additional support. Provided STRTP staff with interim safety plan--- Joe Staff, LCSW, 1234
93
Pain Points: in Crisis Intervention
• Cannot claim for hours of Crisis Intervention in Emergency Rooms.
• Can only claim for time spent on a well documented intervention of imminent threat!
Review: Collateral
a service activity to a significant support person in a beneficiary's life for the purpose of meeting the needs of the beneficiary in terms of achieving the goals of the beneficiary's client plan. Collateral may include but is not limited to consultation and training of the significant support person(s) to assist in better utilization of specialty mental health services by the beneficiary, consultation and training of the significant support person(s) to assist in better understanding of mental illness, and family counseling with the significant support person(s). The beneficiary may or may not be present for this service activity.
9 CCR §1810.206
94
Rehab users should always bill H2015
95
STRTP Collateral Individual Example Note 4
05-15-2020 134 Mins. SCHOOLP: Madison interrupts class with horseplay and disruptive behavior (seeks attention by snorting)I: Met Madison’s School Aid Coach, Brenda regarding TCP goal to increase Madison’s attention in class and decrease snorting outbursts. R: Brenda welcomed consultation & training on how to ignore and when to redirect Madison’s disruptive classroom behavior. P: Plan is for Brenda to id triggers & precursors to outburst and identify rewards & reinforcers for Madison. Will meet with Madison & Brenda at school on 05-22-2020.-----Lydia Staff, STRTP, MHRS
Review: STRTP Group Notes
When services are being provided to or on behalf of a client by two or more persons at one point in time, each person's involvement shall be documented in the context of the mental health needs of the client.
o Contacts with significant support persons in the client's life are directed exclusively to the mental health needs of the client.
9 CCR §1840.314 and §1840.316
o When a person provides service to or on behalf of more than one client at the same time, the person's time must beprorated to each client. When more than one person provides aservice to more than one client at the same time, the time utilized by all those providing the service shall be addedtogether to yield the total claimable services. The total time claimed shall not exceed the actual time utilized for claimable services.
96
CPT staff: 90853 for other than multiple-family group. All other staff: HCPCS H2015
97
STRTP Direct Service Rehab Group Note Example 1
Name of Group: Who said that?!Group Goal: Instructing youth on Problem Solving skills to promote cooperation, collaboration, turn-taking and following directions.No. Client’s represented in Group: 6 No. of Staff: 2 Time: 121 minsToday's Focus: Incorporating “Simon Says” game with praise to reinforce following directions. Staff member Jill Doe, LCSW focused on how wait, take turns and follow directions. I reviewed last week’s group problem-solving homework with each individual member, redirecting as needed.Client Response (include individual client's behaviors/target symptoms/level of participation/clinical intervention): Jorge had great difficulty waiting for his turn. Jorge was easily frustrated with this exercise, “I don’t know how this is going to help!” Jorge’s problem solving assignment was blank, calling it “stupid.” Plan is to continue to work with Jorge on effective communication, and practicing turn taking and how to track his successes------------------------------------------------Joe STRTP MHRS
98
Rehab STRTP Group Note Example 2 (English as Second Language)
Name of Group: Getting my Message Across Skill GroupGroup Goal: Assisting Youth in Improving coping skills using role play and role reversalNo. Client’s represented in Group: 6 No. of Staff: 1 Location: STRTP HomeToday's Focus: Use of “I” statementsClient Response (include client's behaviors/target symptoms/level of participation/clinical intervention): Service provided in Spanish. Introduced concepts of using “I” statements when frustrated. Elsa admits resorting to yelling and intimidation when angry. Worked with Elsa in role play providing positive feedback and praise when she was able to share her feelings, “I do not like being told what to do over and over. I feel like I am not trusted.” Elsa said she liked this group.Plan is to continue with this skill-building exercise------Jaime Staff, STRTP MHRS
99
Rehab STRTP Group Note Example 3
Name of Group: Give me a Break!Group Goal: Using Progressive Relaxation skills to decrease stress.No. Client’s represented in Group: 5 No. of Staff: 2 Time: 90 minsToday's Focus: Taking breaks and focus on breathing to self-soothSTRTP ICC Coordinator Jill Doe, introduced group on how to identify triggers of their stress sharing with group members how their stress can result in negative feelings can unintentionally impact other STRTP residents. I introduced exercise on progressive relaxation breathing exerciseClient Response (include client's behaviors/target symptoms/level of participation/clinical intervention):Madison states living with her STRTP roommate was a great source of her stress and plans on using this breathing exercise to help her to de-stress. Madison did well and helped others in group. Plan is to introduce more de-stressing exercises for coping with different situations -----Joe Staff, STRTP MHRS
100
What is wrong with this STRTP Collateral Group Note 4? (hint: 6 major issues!)
Name of Group: STRTP Staff Education Group
Group Goal: Educating STRTP staff on intervention strategies
No. Client’s represented in Group: 6 No. of Staff: 2 Time: 1200 mins
Today's Focus: Effective use of Intervention techniques to address youth’s behavior problemsClient Response (include client's behaviors/target symptoms/level of participation/clinical intervention):Staff member Jill Doe, MHRS introduced the value of quality time and how to reinforce positive behaviors to replace misbehavior and avoid incidents of rewarding negative behavior. I made Copies and scheduled alternative group meeting date next week due to my vacation .---TessStaff MFT-Intern
Cannot claim for generalized staff training and education
No explanation what the second staff member did to justify 2nd staff claiming
Too Much time claimed! Lack focused benefit for individual
client Billed for an administrative activity
(copies and appointment Scheduled) Missing staff’s Registration number
101
ANSWER: Problems with STRTP Group Collateral Note 4:
102
Name of Group: Stay away from me!Group Goal: We worked with 8 clients on how to better get their needs met by using effective communication .No. Client’s represented in Group: 5 No. of Staff: 2 Time: 92 minsToday's Focus: Jill Doe, LCSW and I focused on how to tell others you need space using good eye-contact, clear, calm instructions, use of respectful space and use of “I” statements. We also reviewed last week’s skill assignments and outcomes.Client Response (include client's behaviors/target symptoms/level of participation/clinical intervention):In today’s group we reviewed with residents last week’s homework and provided individual feedback. We shared how timing, praise and repetition will reinforce compliance. The residents were very receptive to new skills. Each member successfully practiced and role modeled in group. We closed with a group activity that reinforced and modeled topics presented today. Anna Staff
What is wrong with this STRTP Rehab Group Note 5? (hint: 7 major issues)
ANSWER: Problems with Group Collateral Note 5:
Where is the word “skill”? Number of Clients in group does not match. No “Time” noted Each staff member’s role in group is not
defined (coat-tailing) Not individualized or linked to this specific
client’s goal/plan No Plan or Follow-up documented No staff Title following signature
103
1 Include the “Skill” in Rehab Groups and what was the “consultation & training” in Collateral Groups
2 Focus exclusively on the client’s benefit & address Medical Necessity
3Count the Number of clients represented in the group regardless of funding stream. Make sure number of staff and clients present is correct
4 Individualize, not generalize. Include client’s specific Medical Necessity. Include client quotes
5 Each staff claiming has a documented non-duplicative role if providing co-staffing in group
104
Group Note Checklist
105
Intensive Home based Services (IHBS) vs Intensive Care Coordination (ICC) vs. Mental Health Services and Case Management
106
INTENSIVE HOME BASED SERVICES (IHBS)
Individualized, strength-based interventions to address the mental health needs of the youth predominantly provided in the home, school, or community. Service includes: Skill based interventions Developing functional skills Developing replacement behaviors
107
INTENSIVE HOME BASED SERVICES (IHBS)
108
Claimable IHBS activities include: Improvement of symptom/self-management Education of mental illness Develop social supports and address behaviors that interfere with
a stable and permanent family life seeking & maintaining a job youth’s educational achievement independent living
IHBS Service in STRTP setting Example Note 1
06-06-2020 38 mins STRTP HomeP: Dorian anxious about getting around once he leaves the STRTP.I: Met with Dorian individually today to work on skill on how to read a VTA bus schedule. Reviewed timetables and how Dorian can plan his route. R: Dorian says he really wants to learn how to get around San Jose using public transit. P: Plan is to accompany Dorian on a planned community meetup using VTA bus. --------Jerome Staff, IHBS Coach 109
IHBS Service in STRTP setting Example Note 2
06-12-2020 98 mins STRTP HomeP: Dorian anxious about getting around once he leaves the STRTP.I: Met with Dorian individually today to work on skill on how to use public transit. Dorian was very frustrated while waiting for the VTA bus. Worked with Dorian on progressive breathing exercise to decrease his anxiety. Dorian stated this helped and we took bus to the Starbucks. R: Praised Dorian for starting deep breathing on his own during return trip to STRTP. P: Plan is to practice different routes and let Dorian take charge.-----------Jerome Staff, IHBS Coach 110
Intensive Care Coordination (ICC)
Ensuring ALL System Partners and their plans (i.e., mental health, child welfare, special education, juvenile probation, etc.) are comprehensive, integrated and coordinated to address the child or youth and/or family goals and objectives, to support and ensure successful and enduring change.
111
ICC Coordinated ServicesHelping the child/youth to succeed in the home and community by building new skills, helping families to access community supports, and ensuring that all service providers are “on the same page” and working together.
112
Intensive Care Coordination (ICC) vs Targeted Case Management (TCM)
ICC must be delivered using a CFT, and is intended for children and youth with more intensive needs and/or whose treatment requires cross-agency collaboration.
ONE designated ICC Coordinator ICC Coordinator can identify behavioral
health need outside STRTP and coordinate a multi-agency response.
113
ICC Transition Plan Development Progress Note in an STRTP Example
06-11-2020 20 Mins. STRTP HomeI spoke with Lydia, the ICC Coordinator about Miyeun’s planned discharge on July 10, 2020. STRTP will support Miyuen’s successful transition back to her mother’s home in the community by providing mother with step-down coordinated care referrals and support goals established by Miyeun with her community support team to aid and assist in successful transition. Will present transition plan in CFT to coordinate services upon STRTP discharge. -------Jill STRTP, LCSW 1234
114
ICC Coordinator Progress Note in an STRTP Example
06-11-2020 40 Mins. STRTP HomeI spoke with County Social Worker, Roxanne regarding Miyeun’s planned discharge on July 10, 2020. STRTP will provide and ensure that Miyuen’s mother has linked with step-down coordinated care referrals and support group. IHBS worker will continue to work individually with Miyeun on her reunification and transition support goals established by Miyeun & her mother in the CFT. Miyuen’s school aide has established a weekly “update” with Miyeun & mother for tracking educational goals. Plan is to follow-up coordination at CFT Meeting next week. ---------------------------Lydia Staff, STRTP ICC Coordinator 115
Staff Roles and Service Overlap Role Fidelity: Therapy notes vs. Rehab notes Focus of Intervention: Clearly assigning
focus. Consider if with an Individual vs. Group Collateral: (individual and group) always with
a Significant Support Persons Rehab: (individual and group) always with
Child/youth IHBS :is always individual and strength-based
focus on self-care and independent living skills ICC Coordinator: Centralized Hub, like a
conductor, cross-agency, collaborative
116
PRACTICE TIME
You will be randomly assigned to an on-line chat room.
You will be provided a Vignette
Answer the following questions as a group:
117
Vignette Analysis: Use the following guide with each Vignette
What to rule out first? (LPHA)
What are the functional impairment? (ALL)
Possible Primary Diagnosis? (LPHA)
Does it meet Medical Necessity and why? (ALL)
Recommendations for an intervention to (diminish, prevent, or allow developmental progress, one, two, all three?)
Compose a Rehab Progress Note together. Required elements for Rehab notes? Cultural Considerations? (ALL)
118
Do’s and Don’t EVER!
Progress Note and Claiming Guidance (see Disallowance Crosswalk)
119
Progress Note Do’s
Include time, date, type of contact Include all contacts Brief, succinct Include client plan behavior being addressed
or mitigated Include TCP interventions or actions Include follow-up plan or next step(s) Sign it, include title and License/Registration
No. (electronically okay) Consult with supervisor when in doubt
120
Don’t EVER… (see: Red Flag Crosswalk)
Disallowed Claiming for: Transport Providing Mental Health Services to a person
other than the client Clerical Activities (filing, copying, faxing) Making/Cancelling an Appointment No Shows without action. Translating or Interpreting Researching a topic or intervention Recreation or Vocational Intervention/training
121
Contacting SCC Quality Improvement
The Quality Improvement Program oversees program compliance to all local, State, and Federal Guidelines for quality of care, certification, and utilization management.
Phone 1 (408) 793-5894
122
Questions?
123
124
Please Note
No part of this presentation or its handouts may be reproduced, translated, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission of the Presenter
