Service Authorization Request - Justification (SARJ)

1. Service Authorization Request - Justification (SARJ) Community Access to Recovery Services Milwaukee County Behavioral Health Division

2. The 8 Dimensions ASAM ASAM DIMENSION SEVERITY SUMMARY No Problem (0) / Mild (1) / Moderate (2) / Severe (3) / Extremely Severe (4)

3. A Sample of the Behavioral Anchors in ASAM Dimension 3

4. The SARJ – Purpose and Rationale Designed to provide both quantitative and qualitative data to justify requests for: • Continued stay at a given level of care • Transfer from a given level of care to a lower/higher level of care or a comparable level of care at a different agency • Additional services across CARS service array (e.g., RSS Housing, RSS Employment services, Peer Support Services, Case Management Services (RSC/CSP/TCM/CCS), etc.)

5. The SARJ – Purpose and Rationale Cont’d The SARJ also enables us to use quantitative data to track a person’s recovery trajectory This data can be utilized not only as outcomes data, but as informational data to provide guidance to providers to drive level of care placement decisions. Examples: • Outcomes Data: Does the ASAM Dimension 7 Score decrease for individuals in AODA Transitional Residential Care between intake and discharge • Placement Decisions: If all of a client’s Dimensional scores are 2 or below, this suggests they should be discharged to a lower level of care (or, at least, a transfer should be considered)* * If a discharge is not requested in this scenario, then a clear rationale for continuation must be provided

6. ASAM Domain Score Crosswalk

7. Service Authorization Request –Justification [on paper]

8. The CARS SARJ in Provider Connect *Note that the SARJ now allows for up to three services to be requested on one SARJ

9. The CARS SARJ in Provider Connect Cont’d

10. The CARS SARJ in Avatar

11. The CARS SARJ in Avatar Cont’d

12. Things to Note when Completing a SARJ Services offered by the County are based on client choice as well as clinical need. SARJ’s for a continuation of services should also include a Service Authorization Request. SARJ’s can include one, two, or even up to three services [this is a relatively newer feature]. If a SARJ includes more than one service, the “Service Recommendation and Plan” as well as the “Alternative Plan” must address each of the requested services specifically. Provide an appropriate rationale, particularly for those Dimensions that remain high/have increased and/or those that are your primary source of concern/focus of treatment

13. Tips for Completing a SARJ • The SARJ must be completed and submitted 7 days beforethe authorization expires. • Each dimension of the SARJ should be specific to that dimension. For example, information on a client’s mental health should be discussed in dimension 3. However it does not need to be restated in that same detail again in other dimensions. Repetition doesn’t always mean a better SARJ. It’s about quality and not quantity. • The SARJ is your time to advocate for a client. You know them best.

14. What else you need to know when Completing a SARJ In each Dimension, select the appropriate criteria Provide an ASAM Dimensional rating in ALL 8 Dimensions, even if the rating is a zero • If the score is zero, comments should include “why” or a comment addressing it. Comment spaces should not be left blank. Provide an appropriate rationale, particularly for those Dimensions that remain high/have increased and/or those that are your primary source of concern/focus of treatment Specify ongoing treatment/recovery plan goals if the client continues in the given level of care, AND detail an alternative plan should the request for continuation be denied. These items are under “Service Recommendations and Plan” and “Alternative Plan”.

15. 3 Types of Authorization Requests • Additional Services • Requesting services that client is not currently receiving [i.e. RSS Housing; RSS Employment; Case Management; etc.] • Continuation • Continuing with the current level of care • Transfer • Transferring a client to comparable level of care with different provider

16. Completing a SARJ:The Good, the Bad, and the Ugly

17. “Good” SARJ Tips Clinical details that speak to the domain • Client has mental health issues and Dimension 3 reports current updates on this. SARJ corresponds to service request(s), case notes and RPOC/treatment plan • consistency across sources Weave client’s pertinent history into the updated information report • “Though he has been progressing with his abstinence and recovery, the client continues to struggle with mental health issues related to the loss of his son. He continues to grapple with expressing his emotions in a healthy manner that does not include substance use. This client has a prior diagnosis of depression and reports having used heroin to stabilize his emotions and feelings in the past.” Describe what client is thinking and what he/she wants • “Client eventually wants to transfer to Bridge Housing with Day Treatment so he can work, as obtaining an income is a priority for him. Client feels he has been progressing well however has recently been struggling in two domains. Clinician suggested a two week transition period. After the two weeks, clinician and client will reevaluate progress.”

18. “Good” SARJ Tips Continued… Describe the client’s health insurance status including steps taken to apply. A client’s employment/income and potentially debts should also be discussed particularly for housing requests. Recovery Environment described in detail. • “Client cannot return home due to his family members using in the house. Client interviewed with bridge housing provider and has been waitlisted.” • “Client returning home to partner who is in recovery, attends support groups and will in turn offer support to client. Client’s family has been supportive, in particular his father, who has 20 years of sobriety.” Alternate Plan completed with information including community resources available for client. • “Client will transition to Our Safe Place for which he is currently on the wait-list, pending availability. He will continue to reach out to his sober friends as an alternative plan for housing. Client will also continue to call 211 and agreed to stay at the Rescue Mission if needed. Client will need to be set up with Day Treatment at a provider of his choosing. Client will continue to attend outside support meetings and work with his sponsor to begin building his informal supports in the community. Client will continue to work with his RSC for employment and permanent housing. Client will continue to see his Therapist at the Healing Corner and address his past trauma.”

19. “Good” SARJ – Examples Dimension 1 Score: 1 Dimension 1 Comments: • Client has history of substance abuse; his drugs of choice being alcohol and heroin. Prior to admission, client was drinking on a daily basis and would often drink to the point of blacking out. Withdrawal symptoms included lack of appetite and mood changes. Client was also using heroin [IV] on a daily basis. His withdrawal symptoms included behavioral and mood changes. Client last used both alcohol and heroin just prior to entering residential treatment three weeks ago. Client has agreed to Vivitrol and is scheduled to receive his first injection tomorrow. Dimension 7 Score: 2 Dimension 7 Comments: • While in residential, client has not used alcohol or heroin and greatly reduced/abstained his use of cigarettes. Prior to this, he was drinking daily or almost daily, generally vodka. He was also using heroin on a daily basis; buying and using it when he could or having friends purchase it for him. Client would continue to use substances regardless of how he was doing medically. For example, even when he was experiencing severe ulcers, he would continue to drink alcohol daily causing him to experience discomfort. Client had no desire to stop or reduce his use. His sobriety came when he began declining medically and was unable to function at a level that would give him the ability to use.

20. “Good” SARJ – Examples Continued • Dimension 3 Score: 3 • Dimension 3 Comments: • Client reported previous diagnosis of depression and anxiety. Client has been exploring abuse history more openly in individual sessions. At this time, client demonstrates poor coping skills for dealing with day to day stressors. He requires daily support from his mother and/or peers and tends to de-stabilize very easily. Client tends to become either overly attached or tends to create chaos in relationships. Developmentally, client responds much younger than stated age a large percentage of the time. When he decompensates, he becomes almost child-like. However, client is making efforts to understand how to develop safe emotional boundaries. He is also showing improvement around tendency to isolate. Client remains vulnerable in regards to mental health. Services are being put in place to assist client but he has been quite reluctant to understanding the need for mental health services. • Dimension 4 Score: 3 • Dimension 4 Comments: • Client had little to no insight into his mental health and AODA issues and an internal locus of control but a lack of accepting responsibilities for his actions. Prior to entering residential, client was making his contacts with his treatment team and was medication adherent. However, he continued to use alcohol and heroin regardless of physical, medical, and environmental consequences. For example, he was living with his sister and was told if he continued to use he would not be welcome to stay there any longer. Client continued to use, was kicked out, and had to move to the Rescue Mission.

21. “Bad” SARJ - Examples Not enough information offered to justify request • “The client needs this level of care” • Why? • “Client would be homeless if not at a Residential level of care” • Residential Treatment is not housing. Needing “housing” is not a justification for continuing in a residential level of care. So what other criteria is there for residential treatment? Information is inconsistent • Example: Dimension 2 lists mental health medications. On same SARJ, Dimension 3 states: “No emotional or behavioral problems reported” Alternative Plans stating that clients have no alternative plan • “Client needs daily structure at this level of care to sustain treatment goals.” • It is not an option to just not include an alternative plan because you feel that the client’s authorization should be extended.

22. “Bad” SARJ – Examples continued • Information is listed under wrong SARJ dimension • Information is repeated throughout • Example: Putting a phrase such as “Client has been diagnosed with Bipolar Disorder” in 5 of the 8 dimensions. It is enough to include it once unless there is a specific reason it is being mentioned again. MH information should be included primarily in dimension 3. • Comments are too general • “Client has coping problems” • Coping with what? • “Client has emotional/behavioral or cognitive problems” • Of what kind? • Are they engaged in additional services to address this?

23. “Ugly” SARJ - Examples • While we at CARS appreciate details, there is such a thing as “too much”. SARJ’s should be clear, concise, and to the point. They should also be strength based and current. • Dimension 7 comments:  Client has been diagnosed with severe alcohol use and severe marijuana use disorders. Client reports the following substance use disorder symptomology: blackouts, increase in tolerance, hallucinations, alteration thought process, paranoia, memory loss, weight loss, sneaking/hiding substances, morning use, preoccupation with using, switching substances, attempts to control use, alibis or excuses to use, family problems, loneliness, guilt about behavior, sleeping problems, mood swings, feeling depressed, feeling hopeless about the future, fights/aggressive behavior, serious problems thinking, concentrating, and making decisions. Client substance use history is as follows: alcohol 2-8 shots daily + beer, marijuana 1-5 blunts daily. Last use was 8 months ago. • Some of this information could be pertinent however if this client has not used substances in 8 months, it likely it’s going to be very relevant in present time. What’s client’s use been over the past 30 days?

24. Service Authorization Request [SAR] A Service Authorization Request (SAR) is the method of requesting additional funding for consumer services.

25. SAR Tips In order for a provider to be paid for services, there must be an active SAR in the system. It is not always your responsibility to put in a SAR, particularly if it’s for an “additional service” • If you’re not sure, ask. Please be sure that when entering a SAR, you’re putting in the correct procedure codes/units. Also use the Voucher Calendar to ensure that you’re putting in the correct dates. Please make sure you’re reviewing SAR comments made by CARS AODA staff.

26. Where can I find additional training materials NEW BHD Website • Milwaukee County redesigned their entire website. Check it out! • Web Address: https://county.milwaukee.gov/EN/DHHS/BHD Provider Portal • This section of the website contains all of the forms, policies, etc. that you are used to seeing on the old site. • Web Address: https://county.milwaukee.gov/EN/DHHS/Provider-Portal/BHD-Providers BHD Training Page • This section includes tons of great training content, with more being added all the time. Some highlights include sections specifically for Avatar content and ProviderConnect content • Web Address: https://county.milwaukee.gov/EN/DHHS/Provider-Portal/BHD-Training

27. Questions? CARS AODA Staff • Shari Gresk 257.7199 • DTC; MAT; Residential • Lisa Lollis 257.6545 • Residential • Mary Ann Repnik 257.6922 • MHOP; RSS • Christina Schultz 257.7768 • RSS; Detox; MAT Research and Evaluation Team • Adrienne Sulma 257.7312 • Gary Kraft 257.6424