Overview of Behavioral Health Redesign

1. Overview of Behavioral Health Redesign Summit Psychological Associates, Inc.

2. State of Ohio Behavioral Health Redesign • State will require changes as of January 1, 2018 • Managed Care changes will go into effect as of July 1, 2018 • SPA has already been implementing the changes since June 2017 so we can have a smooth transition

3. Supervision

4. Supervision • Non-independently licensed Clinicians will continue to identify which supervisor was on site while the billable activity was performed. • The supervisor does not have to be in the room or free from another activity to be indicated as the supervisor. The supervisor must be”immediately available and interruptible” - accessible in person in case of an emergency. This does not mean accessible by phone or text only - it means the supervisor can be interrupted and walk over to assist in session if needed. For non-trainee clinicians this supervisor can change from week to week for a client. • This does not apply to case management services. • The supervisor who is identified as “direct supervisor” has to be sent any documents needing co-signed (DAs, DA Updates, ISPs, ISP reviews)

5. Supervision • On all of our Carelogic documents, clinicians complete the “Supervising/Ordering Entry Module” • If a supervisor was directly accessible and on site – the non independent clinician chooses the bullet for “Supervision” and indicates in the Staff field which supervisor was directly accessible. The supervisor just has to be available to choose “Supervision” – they don’t have to be utilized. • If a supervisor was not on site during the time of the activity then the non-independent clinician chooses the bullet “No Supervision” and does not choose a staff member. Choosing “No Supervision” does not mean the services were not supervised – it means general supervision was provided but no supervisor was directly available at the time of that service.

6. Supervision for Trainees • Trainees at SPA are the Psychology Interns and anyone completing a Field Placement through their school program • Trainees must have their supervisor meet a MCD client at the DA in addition to having the under supervision form completed. The supervisor that meets the client has to be the supervisor who is chosen for the supervisor each week the client attends sessions. If that supervisor is out of the building or on vacation, then the note for that client would say “No supervision.” • All documentation needs co-signed and has to be sent to the supervisor who met the client. • The supervisor will also be scheduled once a quarter to stop and see the client at the beginning of a session if they do not see them naturally in group or have met with them for another reason. For both the DA and quarterly meetings, the supervisor can stick her head in group and re-introduce herself.

7. Supervision for Trainees • DAs and Progress Notes will ask if the client is Medicaid – if the clinician responds yes, the prompt will come up to ask if the clinician is a trainee, if yes, it will ask which supervisor met with the client. On a progress note, it will ask if the supervisor met with the client that week (for the quarterly meeting) so we can track if a quarterly meeting has already occurred. • Psychology Interns will have a Message Board on the schedule under the client’s name that reminds them they are Medicaid and which supervisor is scheduled to meet with the client at the DA. This will also remind which supervisor to put in the supervision module and to which one all documentation should be sent for review.

8. Supervision Module for Independent Clinicians • Independently licensed clinicians will always choose “No supervision” • Non-independent clinicians will choose between “Supervision” and “No Supervision.”

9. Co-signing for Supervising Independent Clinicians • Clinicians have to complete and sign their documentation by the end of the next business day (with everything statused by the end of the day) • Supervisors must review and co-sign within 72 hours (business hours) of the supervisee’s signature. (If an intern signs on Monday, the psychologist has to sign by Thursday) • Nothing will be billed out until the supervisor has signed.

10. Supervision • The Dashboard on Carelogic will identify daily which supervisors are present at each location. • For psychology interns – the supervisor who met the client at the DA should be chosen for the supervision module and to co-sign the documentation. • For all non-independent clinicians in Akron, choose Dr. O’Bradovich as the supervisor if she is present and only the DAs would need to be cosigned by Dr. O’Bradovich and she can do this within the 72 hour time frame. Supervision toward licensure will still occur as normal and supervising all clinical cases should still be done with this supervisor even though SO might review the documentation and provide additional supervision.

11. Diagnostic Assessments

12. Diagnostic Assessment • Must be completed in one session with a focus on obtaining the necessary information to identify a diagnosis and treatment needs for the client. The DA will have to be completed and signed by the end of the next business day. Supervision and Peer Review will continue to reflect that the DA can only obtain a certain amount of information and that additional information to flush out diagnoses and further direction in treatment will be shown in subsequent treatment notes. • There will be no additional sessions for DAs unless a crisis occurs in the DA session. If a crisis occurs in the first session, then the process for a pre-authorization for a second DA session will be completed. • The second session progress note will allow clinicians to use the second session to complete the ISP and the orientation documentation with the client – including prompts for with the ISP being completed in the second session when treatment begins.

13. Diagnostic Assessment • The DA is not complete unless the medication section has been completed. • The clinician should list current medications in the medical section – however, the medications need entered into Dr. First by the support staff by the end of the next business day or the form cannot be signed. • Clinicians should immediately give the client form to their support staff upon ending the first DA session and verify that the medications are entered before signing.

14. Diagnostic Assessments • A diagnosis (or multiple) is still required with the one session DA. • A clinician can begin with a preliminary diagnosis and then clarify the diagnosis as treatment continues (which should be done anyway).

15. Crisis Sessions • Based on further clarification, SPA will not be billing under crisis sessions because we are not certified to provide crisis services. • QA will be identifying the requirements for obtaining certification as a crisis provider. • Currently, crisis will not be an option on the Additional Services Module for SPA.

16. Diagnoses and documentation • With BH redesign, clinicians have to be more deliberate in their documentation to connect the services provided to the diagnoses they are using. • Clinicians should link treatment provided to an ongoing diagnosis either in the treatment provided or in the response to treatment. If client has major depression – we need to link services to this diagnosis – “Practiced positive self talk to address negative self image” or personality disorder “Identified thinking errors related to getting needs met in relationship” • Diagnosis has to fit treatment - If have a chronic illness like Diabetes but go to the doctor for a sinus infection, the diagnosis for that visit would be “sinus injection” not “diabetes.”

17. Diagnoses and documentation • When managed care begins in July 2018, we will have limits on the length of time a client can have an unspecified diagnosis and authorizations for additional treatment (like testing) will not be approved with an unspecified diagnosis. • Need to further clarify unspecified diagnoses after the DA and need to move to a specified diagnosis if nothing else fits – “Personality Disorder with antisocial traits”

18. Interactive Complexity

19. Interactive Complexity • Definition – Refers to specific communication factors that complicate the delivery of services and occur during the delivery of the service. • Common situations – difficult communication with discordant or emotional family members and engagement of verbally undeveloped or impaired clients. • Won’t be used frequently and cannot be used for only having an interpreter in the room – it cannot be just a time issue – that it takes more time (for instance someone who stutters) but for communication that makes the treatment more complex – reflects added intensity – not added time – is not meant to be used with every “difficult“ client.

20. Interactive Complexity • Interactive Complexity is included (and documented clearly) when at least one of the following is present during the visit: • The need to manage maladaptive communication(related to, e.g. High anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care. • Caregiver emotions or behaviors that interfere with implementation of the treatment plan. • Evidence or disclosure of a sentinel event and mandated report to a third party (e.g. Abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with the patient and other visit participants.

21. Interactive Complexity • More often present with clients who: • Have other individuals legally responsible for their care, such as minors or adults with guardians • Requests others to be involved in their care during the visit, such as adults accompanied by one or more participating family members • Require the involvement of other third parties, such as child protective agencies, parole, probation officer or schools. • These are not billed just for having an interpreter present.

22. Interactive Complexity • The need to manage maladaptive communication(related to, e.g. High anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care. • Examples • During court ordered therapy the client is angry and explosive throughout the session and refuses to engage or participate in the treatment plan • The participating spouse disagrees with the treatment plan because is in denial about the severity of the drug problem and suicidal ideation the client presents

23. Interactive Complexity • Caregiver emotions or behaviors that interfere with implementation of the treatment plan. • Parent has significant anxiety over diagnosis and recommended treatment and is dealing with only feelings of guilt and anger that the treatment plan cannot be fully completed or explained to the parent.

24. Interactive Complexity • Evidence or disclosure of a sentinel event and mandated report to a third party (e.g. Abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with the patient and other visit participants. • Disclosure of child abuse/neglect, elder abuse, self harm or harm to others with discussion in session with client and other participants

25. Interactive Complexity • These are not billed as Interactive Complexities: • Multiple participants in the session but communication is straightforward • Client attends session individually with no sentinel event or language barriers • Treatment plan is explained in session and understood without significant interference by caretaker emotions or behaviors

26. Case management/cpst for clinicians

27. Case management/cpst for clinicians • Case Management is for clients with Substance Abuse diagnoses receiving substance abuse treatment from SPA • CPST is for clients with mental health diagnoses

28. Case management/cpst for clinicians • This is not a substitute for clients that need traditional CM or CPST and those clients should be referred to case management. • Case Management and CPST can be billed by the a clinician in the following situations: • If Case Management/CPST is identified as an activity that can be done by the therapist on the ISP • If the activity supports the client in the obtainment of the ISP goals • If the activity lasts longer than 8 minutes

29. Case management/cpst for clinicians • Examples of clinician CM/CPST activities as long as meet earlier criteria: • Face to Face or phone consultation with primary care doctor or client’s psychiatrist • Phone contact with the client that works toward them attending sessions, identifying barriers (not just leaving a ‘where are you’ message) • Completing a monthly for the SSA detailing progress in treatment or barriers to progress • Phone consultation with SCCS regarding a client they referred • Attending a planning meeting for a client with DD • Consulting with a clinician who provides another form of treatment with that client (group leader, case manager) – only one clinician can bill for this activity – it cannot be both • Speaking with a PO regarding progress in treatment or barriers to progress

30. Case management/cpst for clinicians • Clinician will have to enter the CM/CPST activity into their schedule as a billable client activity (click on the C for adding a client activity). If marked a client as NS – it will open up that hour and CM/CPST can be completed in that time. • The activity should be set up for the actual time done (1:05 to 1:23 – for 18 minutes) and the activity should be kept. • The Activity to choose is either Case Management (AoD) for Clinician or CPST (MH) for Clinician

31. Case management/cpst for clinicians • If client program does not pre-populate then have to choose between forensic, non-forensic or vivitrol. • If location does not pre-populate you choose “Office” • You can put a description in the box that will show up on the schedule but this is not required.

33. Case management/cpst for clinicians • The activity will be linked to a progress note and the clinician will choose either CM or CPST • Choosing these options will remove the sections not required for the CM/CPST note such as mental status or current dangerousness. • This should be statused by the end of the day and as with other documentation must be completed by the end of the next business day. • The note should reflect the amount of time spent in consulting or working with the client outside of session.

34. Psychological testing

35. Psychological Testing • Currently, psychological testing is a global activity that is billed regardless of the test that is given. • As of January 1, 2018, each psychological test will have its own activity – so a client will be scheduled for an MMPI rather than scheduled for psychological testing. • Clinicians can now bill for administration, interpretation and report writing time up to 12 hours for diagnostic testing and 10 hours for developmental testing per client per calendar year.

36. Psychological Testing • Testing will be administered by clinicians beginning in January and interpretation and report writing will be put in as a billable activity and tracked toward the allowed hours for Medicaid clients. Reports for these evaluations will be due ten days after the testing is completed. • Testing will be scheduled for Medicaid clients after the initial interview and a psychological testing order has to be completed by Dr. O’Bradovich prior to the client being seen for testing.

37. Prior Authorization Work Flow Overview 1. Clinician recognizes that a prior authorization is needed and completes a Prior Authorization Form. The form is turned in to their secretary for processing. 2. Secretary enters in the Prior Authorization information into MITS depending if this is a MH or AoD case 3. Secretary follows up on the status of the request. Medicaid processing can take 2-7 business days. Once the Prior Authorization has been processed, the secretary will update the clinician, enter the information into CareLogics and schedule any appointments that were pending the auth. 4. Clinician can check their caseload or client face sheets in CareLogics for the status 5. Secretary will notify clinician once approved.

38. Prior Authorization Process - Clinician • Clinician identifies need for pre-authorization • Clinician staffs the case with Dr. O’Bradovich in Akron, Star Jones in Canton, or Kristen Kratzer in Ravenna 3. Clinician completes the form 4. Leave the MMIS# blank 5. For the Primary Diagnosis – ICD-10 Diagnosis MUST BE USED 6. Turn form into your secretary completed 7. Client cannot be seen for this activity until the form is either approved or denied. Denials can be appealed.

42. Treatment Groups • Mental Health Treatment Groups will only be authorized for one unit – one hour. • Mental Health Treatment Groups require two leaders if the number of group members is over 12 • Due to contractual obligations, Federal SO groups will remain at 90 minutes. • New Foundations groups will not be able to go over 12 unless there is a co-lead.

43. Accounting of disclosures of PHI form • The accounting of disclosures of PHI form is used in Carelogic when information is disclosed to an agency or a person without a release of information – such as in the case of an ambulance having to be called because of a medical problem for a client or a disclosure to SCCS in the case of child abuse.

45. Uds collection for smart programuds orders • Medicaid will allow billing for UDS collection that is ordered by a physician • The case managers will be completing UDS orders for Dr. McCluskey to review and sign when a client begins the SMART program. These will be done at all offices and all sent to Dr. McCluskey. • UDS collection will have to be completed by clinical staff (case managers) in order to bill for the collection. • This is not impacting the Federal UDS program.