Care Coordination Updates Sept. 29

1. C - Coordinating L - Linking A - Accessing M - Monitoring P - Planning Care Coordination Updates Sept. 29

2. Today’s Agenda Role of Care Coordination Relationships in the Project Service Definitions and rates SMART Updates Summary of Critical Information and updates Welcome

3. In support of Maryland’s RecoveryNet we have trained: • approximately 150 providers of recovery support services • 90 portal program clinicians and Administrators • 30 Care Coordinators This fiscal year

4. We have identified Care Coordination Providers in all 24 jurisdictions. Set up a Statewide Provider Network of 75 recovery support providers with 196 service locations Established 19 portal locations And….

5. 625 unique Individuals have and/or are receiving recovery support services in Maryland $239,826.50 in recovery service dollars have been dedicated to supporting individuals in recovery. Thanks to you!! Most Importantly!!!

6. This coming fiscal year our goal is to serve 2,505 recovering individuals and offer nearly $2.3 million dollars in recovery support services. • In FY 11 there were nearly 8,000 enrollments in residential treatment using public dollars. We still have a way to go!

7. Care Coordinator assists recipients in gaining access to necessary care and medical, behavioral, social, and other services appropriate to their wellness needs promotes sound and appropriate use of resources Our newest and fastest growing SUD Workforce! Description of Care Coordination

8. The functions include: recovery support care planning, referral/linkage, and monitoring/follow up Care Coordination

9. Relationships in the Project Regional Area Coordinators (RAC) –Manage on Regional level Client utilizes RecoveryNet resources to enhance and stabilize recovery Care Coordinators (CC) – Manage on the client level

10. Service Description Requirements Rate The New Rates and Services: October 1

11. One time, face-to-face or telephone* interview with ATR client conducted prior to discharge from residential treatment program : (Requires 3-5 days notice from portal) Purpose: • Engage the client in Care Coordination • Insure that Care Coordinator has information needed to coordinate care and client understands the program • Explain the purpose and process of care coordination • Establish contact schedule • GPRA 6 month follow-up appointment • Unit rate =$100.00 • Maximum unit = 1 Care Coordination Intake Interview

12. *More than 20 miles 0r 30 minutes travel time= Telephone intake with client while still in residential treatment. Less then three -five (business) days notice of client discharge date. Other: Requires RAC approval Telephone Intake Interview type

13. Review and verification of: • Participant Application for RecoveryNet Services. (Faxed or given to Care Coordinator) • Is the application’s first page complete?(pg.1) • Are the needed services identified? (pg.1) • Consent to participate signed?(pg.2-3) • Is the disclosure of last known address signed and are other consented agencies identified? (pgs.4-5) Intake Interview Description

14. Client understands and agrees to ATR requirements for services? (pgs.2-3) • Work with care coordinator • Follow-through on referral to next level of care • Collateral contact information required • GPRA Survey intake, discharge and 6 month follow-up requirements • $15 gift card for 6 month follow-up GPRA and Customer Satisfaction Survey Consent to Participate

15. Is the RecoveryNet Contact Sheet clear and complete? (pgs.6-8) • Has the client identified all possible collateral contacts? ( family members, friends, clinical care provider, recovery support contact, DSS worker, Probation worker, health care provider, shelter outreach, etc.) Collateral Information

16. Is the Consent and Re-Disclosure of Confidential Information form complete? (pg.9) • Have the client and clinician clearly identified and consented information for: • Regional Coordinator and Region • RecoveryNet Services authorized for client • Treatment provider for recommended level of care • Other significant contacts identified by client and clinician Consent

17. Referral to clinically recommended level of care Clinician: • Orients client to ATR requirement for treatment engagement • Assesses and recommends next level of care • Creates a referral and establishes an intake appointment for the client Care Coordinator: • Confirms client understanding of the required referral • Obtains all needed information about the referral • Identifies and resolves with client any obstacles related to the referral • Checks with client to confirm that appointment was kept • Ongoing monitoring of treatment progress, troubleshooting, etc.

18. Service Assessment Needs Matching Form (pg.10) • Are the providers client has selected and been authorized for clearly identified? • Are there any established appointments? • Has client filled-out and signed the Referral Choice Verification? (bottom of the Service Assessment Needs Matching Form) Client choice

19. Is there a recovery plan? (Review plan with clinician and client) • What is the plan? (Goals, objectives, strengths, obstacles, actions or steps) • What are the crisis intervention and relapse prevention plans • Are there action steps in the plan that care coordination can assist with? (i.e. transportation, gap services, vital documents, etc) • ISP/Recovery Plan Template (optional) A Recovery Plan

20. Establishes contact schedule and details (where to call, who to call if.., etc. ) • How to contact care coordinator • Agenda for next contact (what services have been accessed, obstacles, successes, needs, etc.) • Schedule 6 month follow-up GPRA appointment (give client appointment slip) Next Steps

21. Documents the service in the provider’s records • Establish a client file, tracks each encounter (type, date, length), maintains updated contact information, records date of next appointment and GPRA 6 month follow-up. • Enters the encounter in the ATR SMART VMS • End Intake Interview service Documentation of Intake Interview

22. Public transportation that supports client recovery activities. Passes are obtained by Care Coordination Provider agency and disseminated to clients. Providers are reimbursed through the SMART VMS. Includes administrative fee • Public Transportation- Passes • Unit rate= $80.00 • Total Available units= 6 (30 day/ea.) Care Coordination transportation

23. Transportation by taxi, van, or other care coordinator arranged transportation. Care Coordinators are reimbursed for transportation that they approve, arrange and pay for. Transportation must be related to client recovery activity. Max units=200 Unit= $1.00 Transportation by Taxi or van

24. Requires: • Client signature verifying receipt of service • SMART authorization and documented encounter • Documentation in provider’s record Transportation

25. Care Coordination/ Vital Documents -Accessing critical vital documents for clients such as birth certificate, soc. security card, etc, Pays for any fees and administrative costs for obtaining documents. (This service does not pay for any transportation of documents. Includes care coordinator time for task required in document acquisition (cannot charge a unit rate with this)) • Max. units = 2 • Unit rate =$50.00 Care Coordination Vital Documents

26. Requires: Email to RAC and inform of need Document purchase with receipt Document in the provider’s record Obtain client signature of service/goods Document in the SMART VMS Vital documents

27. Goods or services paid for by the Care Coordination Provider and reimbursed at the rate below to the Provider. This is a fund used to supplement client identified needs to temporarily support recovery needs and fill service gaps. Items which are appropriate to voucher include: • Clothing/Hygiene • Food • Medication Gap or Co-pay • Medical Appointment Gap or Co-pay • Grooming • Dental Gap Service or Co-pay • Other- Required goods or services that support recovery and are approved by the Regional Manager. Care Coordination Gap Services

28. Unit rate=$1.00 Max= 200 Requires: • Email RAC and inform of need • Purchase the item alone for/ or with the client • Document purchase with receipt • Document in the provider’s record • Obtain client signature of service/goods • Document in the SMART VMS Gap Services

29. Each client requires a discharge GPRA Survey if: • Clients has 0 voucher activity in the past 30 days (no vouchers have been redeemed) • Client requests discharge and there are no active vouchers • GPRA 6 month follow-up and discharge GPRA coincide. (Client has no additional Care Coordination needs, and/or no other active vouchers and is eligible for the follow-up GPRA) • Client cannot be located and there has been no voucher activity for 30 days Discharge GPRA

30. One time, face-to-face* meeting with client, conducted 5-8 months following admission to ATR, to assess satisfaction with ATR and to complete GPRA follow-up interview. Also includes obtaining client satisfaction information (Customer Satisfaction Survey mailed to ADAA – 55 Wade Ave. Catonsville, MD 21228) and issuing client $15 gift card. (must be completed within the 5-8 month required window) Unit =1 session Total available Units = 1 Unit Rate =$160 *telephone GPRA Waiver can be requested through the Project Director GPRA Follow-up Interview

31. Requires: • tracking and locating client for face to face interview • completing the GPRA Follow-up Interview and entering it in the ATR VMS • Administering and submitting to ADAA the Client Satisfaction Survey (mailing to ADAA) • giving client $15 gift card (i.eWalmart or Target) and documenting clients receipt of gift card with signature • documenting the service in the provider’s records • entering the encounter in the ATR VMS GPRA Follow-up Interview

32. Assessment Rate increases Extension policy Housing Updates

33. FYI: • All clients requesting ATR housing authorization will be assessed for readiness and appropriateness for this service • RACs will interview referring clinicians to obtain answers to questions on the Housing Assessment Form and approve or deny the request. • Care Coordinators requesting housing for their client will also need to follow this procedure Housing Assessment

34. Housing rate will be raised effective Oct.1 • Recovery House $17.86/unit - max=60 da. • Halfway House $45.00/unit - max= 45 da. Extensions in housing vouchers will not be approved after Oct. 1. Clients will need to be prepared to assume the cost of their housing when all appropriated units are consumed. Housing Rate and Extension Status

35. What are we looking at? • Time interval between referral and intake/length of pending status • Number of in-person vs. telephonic intakes • Client voucher burn rates • Billing patterns • Number of closed cases • GPRA Discharge report • GPRA Follow-up Rates Data measures

36. All clients must have authorizations for services in SMART in order to receive the service. This includes Care Coordination. • ATR is not fiscally responsibility for services rendered to clients that do not have authorizations in SMART. • Care Coordinators request or adjust service for their clients by completing the SMART consent referral authorization process (refer to SMART training). • Care Coordinators can change an authorization for current care coordination through the authorization request process in SMART (refer to SMART training). Clarifying ATR Processes

37. New Client Application Form • Updated Care Coordinators Manual • New Rate Schedule • Housing Assessment form • ISP/Recovery Plan Template • SMART Tip Sheets • Updated Provider Directory/forms, etc http://dhmh.maryland.gov/adaa/ What you need

38. Need Help? RAC • Approval to add or adjust client services • Questions about a provider • Data measures • Questions about ATR policy or procedure SMART Helpdesk • Questions/problems in a client record in SMART • Data entry errors • Billing or encounter questions/problems • Questions about administering the GPRA Survey

39. Need help? Portal Clinician: • Set up Intake Interviews • Copy of Client Application • Information about a client’s authorizations, selections, etc • Information about a referral for recommended level of care. State Project Director: • Waiver for telephone GPRA –email dgreen@dhmh.state.md.us • Suggestions to improve process • Questions about data

40. All Care Coordinators are required to attend Care Coordination I and Care Coordination II training. • Ask your RAC about training dates and locations • Technical Assistance is available to all providers. • Talk with your RAC about TA needs. Need Training or Technical Assistance?