Residential Level Transitions: Levels III and IV

1. Residential Level Transitions: Levels III and IV Christina Carter DMHDDSAS October 2009

2. Budget Reductions • FY 2010 budget greatly reduces funding levels for Child Residential Level III and Level IV services for both Medicaid and state funded consumers.

3. System of Care Response By Mutual Agreement • DHHS • Department of Juvenile Justice and Delinquency Prevention • Department of Public Instruction • Administrative Office of the Courts Committed to System of Care (SOC).

4. SOC Principles Required through Transition • Family Driven and Youth Guided • Child and Family Team Based • Natural Supports • Collaboration • Individualized • Culturally and Linguistically • Competent • Strengths Based • Persistence • Outcome Based and Data Driven • Community Based

5. Child and Family Team Process Required • Required for every child in the system • Proven to be integral for successful transition of children/youth residing in Child Residential Level III and Level IV to other medically necessary services. • Prompts utilization of best practice to the maximum extent to determine the appropriate services for youth affected by this legislation.

6. Child and Family Teams All Child and Family Team meetings follow this basic Agenda: • · Discover/Update Strengths • · Discover/Update Needs • · Determine Goals • · Determine Actions

7. Local Management Entity Role • The LME will be the lead agency coordinating and overseeing the transition • The SOC Coordinators, in collaboration with Local Community Collaboratives provide System of Care training and technical assistance to the provider community as needed.

8. LME Role: Triage • LME System of Care Coordinators + LME care coordination staff have triaged most of the list of currently placed youth based on severity of need and authorization timelines. • LME’s are coordinating with Community Support providers in order to ensure compliance timelines of transition plans. • Clinical information used for triage: Most recent ITR Current Person Centered Plan Risk Questionnaire Other Clinical & Medical Info

9. LME Role: Best Practice • LME System of Care Coordinators and/or other LME care coordination staff are expected to attend all Child and Family Team meetings for youth in their catchment areas. ***In cases when this is not possible, a care coordinator will be in close contact with the Community Support Qualified Professional convening the team. • LME System of Care Coordinators will ensure that the Child and Family Team process that occurs for each child/youth follows the best practice principles of the System of Care model.

10. LME Role: Ongoing Learning • Results from the LME Triage process plus the Child and Family Team (CFT) meetings will be coordinated to determine community needs and service gaps.

11. Community Provider Role • Community providers are instrumental in each step of the process. • Community providers supporting individuals will have the most current information available which will be critical for triage, planning, and development of the transition plan. • Other than the family and/or guardian, the current residential provider and the community support provider for each child will be most integral in sharing knowledge of the child with the LME and the CFT. • It is critical that representatives from these agencies attend CFT meetings and have input into the transition planning process.

12. Community Provider Tasks • Participate fully in the CFT process; • Request of Value Options (VO) additional units of CS which may be required in order to assure the successful case management of the child/youth through the transition to alternate services. • Work with the parent and/or legally responsible party and current residential provider to make certain that all are fully informed participants in the process.

13. Community Provider Tasks CS QP identifies appropriate supports for the child/youth through transition. • If the appropriate service is Psychiatric Residential Treatment Facility (PRTF) the CS QP works with the individual and her/his parent and/or legally responsible person to select a provider agency which meets the needs of the individual. • If the appropriate setting is home: 1.Appropriate supports 2. Appropriate training for family members 3.Appropriate services Intensive In-Home (IIH) or Multi-Systemic Therapy (MST) **The CS QP continues to monitor the progress of the individual in the

14. Level III or Level IV Residential Provider Tasks Level III or Level IV Residential Provider Tasks • The Residential Provider (RP) • Meets with the CFT • Assures the PCP is current • Crisis plan is current (across all domains). • The RP collaborates with the CS QP & participates in the Child & Family Team Meetings • The RP works with the individual to support the discharge plan and to minimize disruption

15. Level III or Level IV Residential Provider Tasks Level III or Level IV Residential Provider Tasks • 3. The Child and Family Team shall fully inform the youth and family of all service options. • 4. The Child and Family Team must develop a discharge plan on the approved DMH/DD/SAS and DMA Discharge Plan • 5. The discharge plan: A. Part of the initial or reauthorization request for all child residential services. B. Required in order for the request to be considered complete C. Failure to submit a complete discharge plan will result in the request being returned as “Unable to Process.”

16. Implementation Update 60: • In addition to the current eligibility criteria documented in DMA Clinical Coverage Policy 8D-2, before a child can be admitted to Level III or Level IV placement the following shall apply: • 1. Placement may be a transition from a Psychiatric Residential Treatment Facility (PRTF) or inpatient setting OR • 2. Multisystemic Therapy (MST) or Intensive In-Home (IIH) services did not meet the youth’s treatment needs within the last six months and severe functional impairments persist; AND • 3. The CFT has reviewed all other alternatives and recommendations and recommends Level III or IV residential placement due to maintaining the health and safety of the child.

17. Implementation Update 60: • For all new admissions to child residential services, length of stay is limited to no more than 120 days. • All requests for a new admission must include a discharge plan in order for the request to be considered complete. • Failure to submit a complete discharge plan will result in the request being returned as “Unable to Process.”

18. Implementation Update 60: • As of September 28, 2009, all concurrent authorizations are limited to a maximum of 90 days after the current authorization expires. All concurrent authorization requests require the following: • 1. A new comprehensive clinical assessment (that addresses co-occurring disorders as appropriate) by a psychiatrist (independent of the residential provider and its provider organization) that includes clinical justification for continued stay at this level of care. • 2. The CFT will review goals and treatment progress. • 3. Family and/or caregivers are actively engaged in treatment goals and objectives. • 4. A revised discharge plan.

19. Implementation Update 60: • A psychiatric assessment justifying the request and a revised discharge plan must be submitted to ValueOptions with the ITR and Person Centered Plan revision including documentation of the review of the CFT. • Requests for Level III and Level IV residential services for children must follow the established Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) procedures and requirements.

20. Implementation Update 60Legislation: 10.68.A.(a)(7(g)(h)(i) • Any residential provider that ceases to function as a provider shall provide written notification to DMA, the Local Management Entity, recipients, and ValueOptions 30 days prior to closing of the business. • Record maintenance is the responsibility of the provider and must be in compliance with record retention requirements. • Records shall also be available to state, federal, and local agencies. • Failure to comply with notification, recipient transition planning, or record maintenance shall be grounds for withholding payment until such activity is concluded. • In addition, failure to comply shall be conditions that prevent enrollment for any Medicaid or State-funded service.

21. Residential III and IV Results:Recipients In Level III and Level IV Residential Services

22. Residential III and IV Results:

23. Residential III and IV Results: • Where CFTs are referring children (in order of need): • Medication Management • Outpatient Individual Therapy • Outpatient Family Therapy • Intensive In Home • Natural Supports • Therapeutic Foster Care • PRTF • Day Tx • Residential Level II • MST • Residential Level III • Residential Level IV • SAIOP • Outpatient Group • Respite • 300-650 Plus referrals • 100-147 referrals • 21-39 referrals

24. Residential III and IV Results: • Services in which some catchment areas require expansion: • Respite • Intensive In Home • MST • SAIOP • Day Tx • Therapeutic Foster Care • PRTF

25. Residential III and IV Results:

26. LME System of Care Coordinators: For More Information on the Residential III and IV Transition Process, go to: http://www.ncdhhs.gov/mhddsas/childandfamily/index-new.htm

27. Inspiration •       “Children are the world's most valuable resource and its best hope for the future”   --John Fitzgerald Kennedy •       “The child must know that he is a miracle, that since the beginning of the world there hasn't been, and until the end of the world there will not be, another child like him.”  --Pablo Casals