Introduction

1. The Integrated Services and Supports Rule (ISSR)Effective March 1, 2010Compliance due by January 1, 2011

2. Introduction • The ISSR integrates AMH certification and licensing requirements for: • Outpatient Mental Health Services • ICTS and ITS Services • Alcohol and Other Drug Outpatient and Residential Treatment Services • Problem Gambling Outpatient and Residential Treatment Services

3. Introduction • Key accomplishments of the integrated rules: • Reflects ideas and requests from stakeholders representing a variety of cultures and viewpoints • Simplifies requirements and documentation • Emphasizes recovery and resiliency • Emphasizes outcome-based planning and service delivery • Updates language (Ex: “Minority Programs” is now “Culturally Specific Programs”)

4. Introduction The ISSR Also: • Includes requirements that promote trauma-informed care • Defines peers, and recognizes peer delivered services • Identifies Young Adults in Transition and Older Adults as specialized populations • Emphasizes collaboration and coordination to promote health and wellness

5. Introduction Alignment with Medicaid Payment Rules: • The documentation requirements in the ISSR are consistent with the federal and state requirements for Medicaid payment. • Requirements for receiving Medicaid payment are found in the Medicaid Payment for Rehabilitative Mental Health Services Rule (309-016-0000 through 309-016-0450) and the Other Contract Services Rule (309-034-0150 through 309-034-0490). • Revisions have been made to the Medicaid payment rules to make them consistent with the ISSR.

6. In this presentation: • Definitions (309-032-1505) • Personnel (309-032-1520) • Entry and Assessment (309-032-1525) • Individual Service and Support Planning and Coordination (309-032-1530) • ICTS Specific Service Standards (309-032-1540 (5-9) • Service Conclusion, Transfer and Continuity of Care (309-032-1550)

7. Structure of the ISSR • The ISSR is structured by content rather than program or level of care. • Each section addresses requirements for all providers, except “Program Specific Service Standards,” and “Facility Standards for Alcohol and Other Drug Residential Treatment Programs.” • There are instances in each section when a requirement will apply only to a specific program. Those requirements are clearly identified (example: ISSP requirements for ITS program).

8. Previous ITS Rules Specified Requirements for: Psychiatric Residential Treatment Services Residential Psychiatric Treatment Programs Psychiatric Residential Treatment Facilities Partial Hospitalization Programs Assessment and Evaluation Substitute Care Settings Sub-Acute Psychiatric Care Psychiatric Day Treatment The ISSR Specifies Requirements for: Psychiatric Residential Treatment Facilities (PRTF) Secure Inpatient Programs for Children and Adolescents (SCIP) and (SAIP) Sub-Acute Psychiatric Care Psychiatric Day Treatment Program Designations in ITS

9. Definitions: Updated Language Client Individual Treatment Services and Supports Treatment Plan Individual Service and Support Plan Progress Note Individual Service Note Clinical Record Individual Service Record Admission Entry Discharge Service Conclusion

10. Definitions: Updated Language Discharge Summary Service Conclusion Summary Behavior Management Behavior Support Special Treatment Procedures Emergency Safety Interventions Minority Program Culturally Specific Program Quality Assurance Quality Assessment and Performance Improvement Quality Assurance Plan Performance Improvement Plan Transition-age Youth Young Adult in Transition

11. Personnel (Page #20) Program Staff • Licensing and credentialing requirements are found in the definitions. • Examples: Qualified Mental Health Professional (QMHP) and Alcohol and Other Drug Treatment Staff

12. Personnel Staff Competencies • General competencies for these positions include specific skills one must demonstrate in addition to the applicable license or certificate. • Examples: Clinical Supervisor, Problem Gambling Treatment Staff, Peer Support Specialist • Providers must have a job description to correspond with each position.

13. Personnel Personnel Documentation (p.21) • Periodic Performance Appraisals: Frequency and content must be consistent with the providers personnel policies. • ITS and AOD Residential Services Only: Hepatitis B and TB screenings for staff are required. • Criminal history checks for “subject individuals.”

14. Personnel Training • Pre-service training includes: • Individual crisis response procedures • Emergency procedures • Program policies and procedures • Individual rights • Mandatory abuse reporting procedures • Population-specific information • An overview of applicable community resources

15. Personnel Training • Ongoing training is at the discretion of the provider, consistent with the provider’s training policy. • Some specified training required: • Behavior Support (ICTS and ITS) • Annual training in CPS, positive behavioral support or other evidence based practice (ICTS and ITS)

16. Personnel Clinical Supervision • All program staff must receive two hours of clinical supervision per month, or a proportional level of supervision for part time staff. • Types of clinical supervision include review of documentation, staff meetings, phone conversations, observation and performance reviews . • At least one hour must be individual face-to-face. • Supervision must be documented and present in the personnel file.

17. Entry and Assessment (Page #23) Entry • Entry process must be consistent with providers written policy and procedure for each type of service. • Entry timelines: “most timely manner feasible consistent with presenting circumstances.” • The same timelines apply for routine, urgent and emergent services.

18. Entry and Assessment • Required documentation for entry: • Written informed consent for services • Individual Service Record (see 309-032-1535 for information to obtain at entry) • Signed Consent for Release of Information • Orientation Packet

19. Entry and Assessment Orientation Packet • The orientation packet must include: • The program’s philosophical approach to providing services and supports • A description of individual rights • An overview of services available • Policies concerning grievances and confidentiality

20. Entry and Assessment Assessment in Mental Health Programs • In Mental Health programs, a Qualified Mental Health Professional (QMHP) must complete the assessment, although a Qualified Mental Health Associate (QMHA) can assist in gathering information.

21. Entry and Assessment Assessment in Alcohol and Other Drug Treatment and Problem Gambling Treatment Programs • In Alcohol and Other Drug Treatment and Problem Gambling Treatment Programs, supervisory or treatment staff can complete an assessment (Definition: Page 2)

22. Entry and Assessment Eligibility Requirements for ICTS/ITS • Requirements for determining eligibility (including the CONS process) are addressed in: • Contracts • CFR • Medicaid Payment Rules

23. Entry and Assessment Provisional Assessment • Provisional assessment is applicable when services are required on an immediate basis. • Documents a provisional diagnosis and identifies the immediate appropriateness of services. • Timeline for completion of a full assessment is dependent on the individual’s circumstances and provider’s policy.

24. Entry and Assessment Assessments must include: • Sufficient biopsychosocial information and documentation to support the presence of a DSM diagnosis that is the medically appropriate reason for services. • “Biopsychosocial information” means the combination of physical, psychological, social, environmental and cultural factors that influence the individual’s development and functioning.

25. Entry and Assessment Screening • Screenings Required in Assessments • Substance use, problem gambling, mental health conditions and chronic medical conditions • Symptoms related to psychological and physical trauma • Risk of suicide or other health and safety concern • No specific screening tools required

26. Entry and Assessment Service Specific Assessment Requirements • Alcohol and Other Drug Treatment Programs: Assessment and diagnosis must be consistent with the dimensions described in the ASAM (PPC)-2R. • Children age zero to five: • Direct observation of parent, child, and family interaction • Neurodevelopmental considerations • Parent and family biopsychosocial functioning within the context of the home, community, and culture. • Problem Gambling: Financial Assessment

27. Entry and Assessment • Co-occurring Disorders: • Screening and identification • Referrals for further assessment, planning and intervention and follow up.

28. Annual Assessments • Annual assessments must be approved by an LMP. • LMP signature must be present 365 days after entry.

29. ISSR Questions?

30. Individual Service and Support Planning and Coordination (page #25) Individual Service and Support Planning • Planning is: • Collaborative • Person-directed and family-driven • Based on information in the assessment • Based on individual and family strengths and resources

31. Individual Service and Support Planning and Coordination Individual Service and Support Plan (ISSP) • Focus is on intended outcomes rather than problems. • Identifies measurable or observable intendedoutcomes. • Identifies services and supports that will “assist the individual and his or her family, if applicable, to achieve intended outcomes.”

32. Individual Service and Support Planning and Coordination ISSP • Can be provisional when services are required on an immediate basis. • A provisional ISSP must identify time lines for completion of the ISSP consistent with the individual’s circumstances and the provider’s policies.

33. Individual Service and Support Planning and Coordination ISSP • The ISSP reflects: • The assessment • The level of care provided • Individual and family participation and direction • Individual and family strengths

34. Individual Service and Support Planning and Coordination ISSP Timelines • Timeline for completion of the ISSP reflects: • Assessment • Timeline identified in the provisional ISSP • Type and level of services and supports • Engagement of the individual and family, if applicable. • Timelines for review of progress and updates to the assessment and ISSP are consistent with: • Level of care and the needs of the individual.

35. Individual Service and Support Planning and Coordination Qualifications for Completing an ISSP • Supervisory or treatment staff in AOD or problem gambling programs • A QMHP in Mental Health programs, with the assistance of a QMHA • A QMHP, who is also a Licensed Healthcare Professional, must sign the ISSP within five days of completion for mental health only.

36. Individual Service and Support Planning and Coordination • All ISSPs include: • Measurable or observable intended outcomes • Specific services and supports to be provided • Applicable service delivery details including frequency and duration of each service. • Criteria for service conclusion • Timelines for review of progress (every 30 days for ITS programs).

37. Additional ITS Requirements • Proactive safety and crisis planning • A Behavior Support Plan • Behavior support is proactive • Data is required to ensure behavior support strategies are effective in minimizing undesired behavior. • Behavior support is not seclusion and restraint • Identification of strengths and needs • Service Coordination Plan • Needs to be updated as documented in the ISSP. • Additions to the Service Plan must be approved (signed) by a QMHP.

38. Additional ITS Requirements • Individual Service Record • In addition to documentation required of all programs, Individual Service Records in ICTS and ITS programs will include: • Level of Service Intensity Determination • Names and contact information for members of child and family team or interdisciplinary team.

39. Additional ITS Requirements • Training • All program staff complete training in collaborative problem solving or other evidence based practice to promote positive behavior annually. • Program staff complete training specific to the strategies specified in the behavior support plan section of the ISSP for individuals to whom they provide services and supports.

40. Additional ITS Requirements • Behavior Support Services (page 36) • Assess behavior from a neurodevelopmental and environmental perspective. • Develop and implement individual behavior support strategies. • Document strategies and measures for tracking progress as a behavior support plan in the ISSP. • Monitor effectiveness for reducing or eliminating emergency safety interventions and increasing positive behavior.

41. Additional ITS Requirements • Emergency Safety Interventions in ITS Programs (page 37) • Emergency Safety Interventions means seclusion and restraint. • Emergency Safety Interventions can only be used when there is an immediate threat of harm to self or others. • Providers must be approved to implement Emergency Safety Interventions. • Approved providers must establish an Emergency Safety Interventions Committee.

42. Additional ITS Requirements • Emergency Safety Interventions Cont. • A certified Emergency Safety Intervention Specialist (CESIS) can now authorize emergency safety interventions. • All program staff must complete division-approved crisis intervention training. • All emergency safety interventions must be authorized by a psychiatrist, licensed practitioner or CESIS. • Program staff trained in crisis intervention must be physically present during any emergency safety intervention. • The qualified person authorizing the intervention must conduct a face to face evaluation within one-hour of the intervention.

43. Additional ITS Requirements • Emergency Safety Interventions Cont. • Any room specifically designed for the use of seclusion must be approved by the division. • Rooms used for seclusion must meet standards in 309-032-1540(9)(h). • Mechanical and Chemical restraint are prohibited.

44. Individual Service and Support Planning and Coordination Individual Service Notes • An Individual Service Note will be recorded each time a service is provided.

45. Individual Service and Support Planning and Coordination Individual Service Notes • Service notes will include: • The specific service • Duration of the service • Date • Location • Signature of person delivering the service, including date signed and credentials • Any significant event or change including mental status, treatment response and recovery status

46. Individual Service and Support Planning and Coordination Individual Service Notes • Individual Service Notes also include periodic review of progress toward intended outcomes consistent with the timelines stated in the ISSP. • Agreed upon revisions to services and supports resulting from the review will be evident in the ISSP.

47. Service Conclusion, Transfer and Continuity of Care (Page #51) • Service Conclusion: • Planned • Summary completed in 30 days from the date service completion was agreed upon with the individual. • Unplanned • Summary completed in 45 days from the date the provider becomes aware that the individual is unlikely to return. • Transfer

48. Service Conclusion, Transfer and Continuity of Care Service Conclusion Summary: • Promotes continuity of care • Required in circumstances described in the definition (page 14) • Includes transition instructions when applicable

49. Service Conclusion, Transfer and Continuity of Care • The Service Conclusion Summary includes: • Date and reason for the conclusion of services or transfer • A summary that describes the effectiveness of services in assisting the individual and his or her family to achieve intended outcomes identified in the ISSP • A plan for personal wellness and resilience, including relapse prevention, where appropriate • Identification of resources to assist the individual and family in accessing recovery and resiliency services and supports

50. For More Information…….. Sandy Minta, Psy.D. Quality Manager Accountable Behavioral Health Alliance sandy@abhabho.org 541-257-2215 ISSR Website: http://www.oregon.gov/DHS/addiction/rule/main.shtml