Behavioral Health Rehabilitation

Access to Counseling Services

1

The following information is not sanctioned by any state or federal agency, you as a licensed or certified and credentialed clinician are ethically and legally responsible for following state/federal regulations in the services you provide.

Disclaimer

Notable Definitions "BH" means behavioral health, which relates to mental,

substance abuse, addictions, gambling, and other diagnosis and treatment."BHRS" means Behavioral Health Rehabilitation Specialist."CM" means case management."LBHP" means a Licensed Behavioral Health Professional."Objectives" means a specific statement of planned accomplishments or results that are specific, measurable, attainable, realistic, and time-limited."Trauma informed" means the recognition and responsiveness to the presence of the effects of past and current traumatic experiences in the lives of members.

Behavioral Health Rehabilitation Specialist

BA or MA degree from an accredited college/univ;

AND*

Completion of the ODMHSAS BHRS training; OR

Cert. Psychiatric Rehab Practitioner credential; OR

Certification as an Alcohol and Drug Counselor; OR

Licensed as a RN withDMHSAS BHRS credential; OR

BHRS prior to 7/1/10 withDMHSAS credential on file.

Behavioral Health Rehabilitation Specialist-

cont’d.

A BHRS, CADC, or LBHP may perform BHR, following a treatment curriculum approved by a LBHP. 

Staff must be appropriately trained in a recognized behavioral/management intervention program such as MANDT, MAB, CAPE or Trauma-Informed Method.

Other requirements are based upon the agency’s accrediting body.

Treatment Team Levels

Agency Clinical Director - determines the scope of practice/directions for treatment on cases

Licensed Behavioral Health Professionals - assessment, treatment plan oversight, psychotherapeutic treatment services, oversight of Rehab and Case Managers

BHRSs - focused on skills development following curriculum & treatment plan approved by the LBHP

Case Managers - focused on finding and linking the individual/family with needed resources, and advocating for them (overseen by the LBHP)

Psycho-Social Rehab Services - (PSR)

PSR is the process of restoring community functioning and well-being

of an individual who has a psychiatric and/or substance abuse

disorder. Rehabilitation work seeks to effect changes in a person’s

environment and in a person’s ability to deal with his/her

environment, so as to facilitate improvement in symptoms or

personal distress.

FOCUS: develop an individuals skills in areas of living life in a healthy

and functional level that increases one’s satisfaction with life!

The Role of the Rehab Worker

Teach skills that complement ideas and concepts processed in therapy.

Provide input goals and objectives for the Treatment Plan.

Help Treatment Team document progress toward identified goals and objectives.

Communicate client needs to treatment team leader.

Promote reward programs that have been set-up with treatment team.

PSR - 8 main Areas

1. Psychiatric

2. Social

3. Vocational/Educational

4. Daily Living Skills

5. Financial

6. Community/Legal

7. Health/Medical

8. Housing

Policies, Rules and Rates

Medicaid Policy - OAC 317:30-5-240 - 249

Outpatient BH Services: are covered when provided under a

full BioPsychoSocial Assessment and Individualized Treatment

Plan conducted by a LBHP. TheTreatment Plan is developed

to treat the identified mental health and/or substance abuse

disorder(s), with the goal of improvement of functioning,

independence, and well-being of the member. The member

must be able to actively participate, have sufficient cognitive

abilities, communication skills, and short term memory to

benefit from treatment.

IndividualRehab Performed face to

face with only the client and the BHRS.

Sessions may include a client’s family/support system in order to focus on the individuals goals/objectives.

Ages 6 and up

Group Rehab

Performed face to face with only the BHRS and a group of clients.

Staffing Ratios:

1 BHRS to 14 adults (18-up)

1 BHRS to 8 children (6-17)

PSR Policy

Community or Office Based

Travel time to and from PSR is NOT reimbursable.

No-show or cancelled appointments cannot be billed.

If a person uses SoonerRide (SR):

Individual PSR, SR is covered

Group PSR, SR is NOT-covered, unless the client has special transportation needs for wheelchair, etc.

PSR Policy

Breaks, meals and times when the client is unable/unwilling to participate are NOT compensable, & must be deducted from billed time.

CMS federal 8-min rule: when you do 8 minutes minimum, then you round up to a 15 min unit.

If you do less than 8 min, then you do not bill that unit.

The BHRS must be present interacting, teaching, and/or supporting the learning objectives of the member for the entire claimed time.

Daily Limits

Individual PSR

6 units/1.5 hours per day maximum allowed

Clinical standard is 1 hour

Time must be age/developmentally appropriate

Group PSR

24 units/6 hrs adults, 16 units/4 hrs children

Group clinical standard is 1 - 1.5 hrs per subject/topic

PSR Rate Schedule

Individual PSR

$11.79 per 15 min

Group PSR

Adult (18 and over)—$2.72 per 15 min

Children (0-17) )—$3.89 per 15 min

Areas of Lawsuit Risk

Being assigned alone to a case without the oversight of a LBHP

Allowing a client to think that you are their therapist.

Attending to crisis situations that are non-medical emergencies.

Having contact with clients outside of sessions.

Crossing the boundary between Rehab and Therapy, or Case Management.

Not carrying professional liability insurance

Being assigned to the same caseload as a family member or friend

Areas of Lawsuit Risk Rendering services to children at inappropriate times of the day.

Transporting clients without proper insurance coverage and permission signatures.

Billing for individual services when group services were rendered.

Not accurately documenting the time-frame within which services were rendered.

Assuming responsibility for the client.

Failing to report abuse and fraud.

Outings which have little to do with teaching skills.

Promising gifts/rewards in exchange for attendance in sessions.

BHRS Safety RulesTake your safety and your clients’ safety very seriously. Follow all state laws and rules.

Do not ever feel that you have to enter or stay in a situation that you do not feel safe, leave immediately, contact your employer and reschedule your appointment at a safe location.

Familiarize yourself with our safety manual.

Trauma-Informed Care

Trauma-informed care is both a philosophy and a way of providing services based on compelling research over the past 20 years. The research indicates the exposure to trauma is not only dramatically more prevalent than previously known, but also closely linked to many detrimental medical, psychological and social outcomes throughout an individual's lifespan.

Exposure to adverse experiences is especially harmful during childhood when the brain is in a rapid stage of development. Immediate behavioral health interventions offer real hope for minimizing negative consequences, but even in situations where the traumatic experiences occurred long ago, new and evidence-based practices can be helpful.

The Adverse Childhood Experiences Study

What does it mean to be a Trauma-Informed Care Agency?

In addition to evidence-based practices, a trauma-informed agency examines every aspect of their management and service delivery systems to ensure they support healing. This includes having an appreciation for the high prevalence of traumatic experiences for all people in our society and particularly in persons who seek and/or receive behavioral health treatment.

What Does It Mean to Create a Culture of Trauma-Informed Care?

Developing a culture of physical and emotional safety for everyone; clients, their families and staff alike.

Having the belief and understanding that everyone is born with the capacity for progressive development, but that this capacity can be derailed by overwhelming life stressors and traumatic experiences. As a result of these events, individuals and systems may develop maladaptive coping skills that make sense in the context of the history. This is true for clients, their family members, as well as staff members at all levels of an agency.

Surfacing and resolving conflicts

Promoting and valuing honest communication.

Respecting everyone's feelings and perspectives, even when they differ

What Does It Mean to Create a Culture of Trauma-Informed Care?-

cont’d.

Maintaining and supporting emotional regulation for self and others.

Extending kindness and compassion while maintaining healthy boundaries.

Working from a strength-based approach that honors the belief that everyone is doing the best he or she knows how.

Having and cultivating a fun attitude with one another about whatever has to be done, as well as doing whatever has to be done with a sense of joy!

Using group process, group problem solving, and creative problem-solving, whenever feasible, for resolution of shared problems.

What is Client-Centered Care?

Client-centered care is an innovative approach to the planning, delivery, and evaluation of care that is grounded in mutually beneficial partnerships among clients, families, and providers. Client-centered care applies to people of all ages, and it may be practiced in any setting.

The Core Concepts of Client-Centered Care

• Dignity and Respect— Practitioners listen to and honor client and family perspectives and choices. Client and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

• Information Sharing— Practitioners communicate and share complete and unbiased information with clients and families in ways that are affirming and useful. Clients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making.

• Participation— Clients and families are encouraged and supported in participating in care and decision-making at the level they choose.

• Collaboration— Clients and families are also included on an agency-wide basis. Leaders collaborate with clients and families in policy and program development, implementation, and evaluation; in facility design; and in professional education, as well as in the delivery of care.

Do you exhibit these competencies?

1. Listens to all symptoms/problems before making moving toward goals and solutions.

2. Is knowledgeable about the person's condition; past and current status.

3. Is very knowledgeable about curricula, procedural changes from their agencies, and/or licensing bodies.

4. Encourages clients and family members to ask questions and participate in the care experience.

5. Gives options for solving problems and suggests ways in which client and family member can participate in care.

Do you exhibit these competencies?- cont’d.

1. Collaborates with client and family member in seeking additional solutions.

2. Volunteers information about agencies that provide additional services and knows how to access those services.

3. Uses familiar terminology or carefully defines new terms; checks that client and family member understand.

4. Takes time and does not seem rushed.

5. Follows through on care and outcomes.

Documenting Progress

Through your work as a BHRS, you will are required to thoroughly document each visit with each client.

Keep in mind that this document is a part of the ongoing assessment and re-assessment of the client’s strengths, needs, abilities, preferences, and liabilities.

It is very important that your progress notes thoroughly document what took place during the session and is directly related to the goals and objectives that are stated in the treatment plan.

You must state clearly in your note which treatment plan goal(s) and objective(s) were addressed during your session with them.

Cycle of Client Care

The Context of Rehab Work

In order to keep the lines between rehabilitation, case management and therapy separate, it is easiest to think of a rehabilitation worker as a teacher.

Using this context, a teacher would not seek out resources for their student, most likely they would refer them to the school counselor or local case manager.

Using this context, a teacher would not talk to a student about their feelings about a particular event, instead they would send the student to see the school counselor.

The Role of Active Learning

Active Learning- a concept in which people participate in their own learning process by involving them in some type of activity where they physically become part of the lesson, i.e. learning by doing.

Methods of active learning- role-playing, simulations, debates, demonstrations, problem solving initiatives, skits, discussions, games, etc.

Based on process rather than outcome

Uses both left and right brain.

–Adapted from Activities That Teach by Tom Jackson

The Process of Active Learning

General Concept presented to individual/group

Specific information about topic given to individual/group

Activity performed

Discussion about actions/consequences during activity

General principals of topic/activity discussed

Specific skills/techniques are discussed along with application to real world situations

Both left and right brain record event for future use

The Process of Active Learning

Recap learned skills and techniques and have client write their own note, or journal things to share with therapist

Client uses skills/techniques in future events to create change

Client process the use of skills/techniques and the event with therapist

-Adapted from Activities That Teach by Tom Jackson

The Learning Environment

Create a physically and emotionally safe environment. Confidentiality should be of utmost importance in community settings. Group sessions should be governed by rules that they group creates.

Establish a “freeze” command.

Remove/time out participants who refuse to cooperate, report this to their therapist.

Keep directions short and to the point.

If possible, demonstrate what you want done.

Prepare for imperfect experiences.

Managing Communication

Focus on only the task at hand and the skills/techniques being learned.

Avoid questions such as, “What feelings do you have about…”

Use questions such as, “Can you give an example of…,” “What part of the activity made you think of…,” “What else can you add…,” “How could we change…,” “Who has a different viewpoint,” etc.

Managing Communication- cont’d.

Redirect participants that feel the need to process their feelings by using the following:

“That’s very important information that needs to be shared with..(Therapist/Case Manger).”

Refocus back to the task at hand by asking if there is a skill that can be used to prevent X occurring next time.

Clients who frequently want to process during rehab may need to keep a journal and be allowed to record feelings to discuss with their therapist at a later time.

Qualities of a Great Behavioral Health Rehabilitation Specialist

Passion to Teach

You need passion to teach others in order to be a good BHRS. Know your subject and show the clients that you are passionate about that subject and they will be willing to learn even more.

Patience

Patience is necessary for a BHRS. You are dealing with people for extended periods of time, so you will have to be quiet and calm with the clients.

Good Communication

You want to be both a good listener and speaker. Getting people to answer questions will involve getting their attention and making them comfortable enough to speak up. You will lose their attention by being dull and speaking in a monotone voice.

Qualities of a Great Behavioral Health Rehabilitation Specialist-

cont’d.Problem Solver

Unique problems arise in the field. You will need to be a problem solver and able to think on your feet when surprises occur in your sessions. You need to know when to step back and staff a situation.

Supportive

Your clients need to know that you are there for them if they need help. Let them know they can come to you for help while, at the same time, practice healthy boundaries.

Able to Interact With all Ages

If you are assigned to work with families, you need to interact with not only the children, but their parents and other clinicians. Make sure you are comfortable with all age groups.

Leadership

You are in a leadership role, and your clients see how you behave. Always be aware of what you say or do (model desired behaviors) because clients are watching and learning from you.

Psychiatric

Teaching Symptom Management

Depression

Anxiety & panic attacks

ADHD

Anger

Trauma

Vocational/Educational

NOT-Tutoring

Coping Skills

Job Application/Résumé Development

Interviewing Skills

Motivation

Customer Service

Social

Relationships

Family

Boundaries

Communications

Community Integration

Daily Living Skills

Hygiene Skills

Food Planning/Preparation

Cleaning/Housekeeping Skills

Safety Knowledge

Scheduling/Time Management

Community/Legal

Accessing Resources (not to be confused with Case Management)

Being an Active Part of one’s community

Presentation skills

Setting up Supports

Taking Charge of Records

Financial

Budgeting

Bill Paying/Utilities

Setting up a Bank Account

Tax Preparation

Saving

Health/Medical

Nutrition

Exercise

Meditation/Relaxation

Medical/Psych Appointment Management

Symptom Management

Learning how to keep Schedules/Logs

Housing - acquiring & maintaining

Housing

Furniture

Safety

Appliances

Maintenance

Case Management

Do Case Management to assist a client in accessing needed resources in their community to live independently.

Don’t perform CM and bill it as PSR!

Go get your CM certification so you can bill for this!!

Progress Notes (PNs)

Focus—What objective(s) were worked on in session? What skills were taught/learned/practiced?

Intervention—What specific techniques/behaviors/suggestions did you use to promote change?

Response—What did the client report? How did the client respond to the intervention(s)? What did they practice?

Plan—What is the client going to work on between now and next session?

Appropriate Terms for BHRS

Use this…

“teaching”

“practicing”

“role playing”

“monitoring the client’s progress on their Tx Plan goals”

“coordinating with the therapist on client care”

Instead of this…

“assessing”

“processing feelings”

“tutoring”

“mentoring "or “coaching”

“parent skills training” (unless the parent is the client)

Required Elements (PNs)

317:30-5-248 Documentation of records [Revised 07-01-10]

Date; Person(s) to whom services were rendered; Start and stop time for each timed treatment session or service;

Original signature of the service provider; Credentials of therapist/service provider;

Specific service plan need(s), goals and/or objectives addressed; Services provided to address need(s), goals and/or objectives;

Progress or barriers to progress made in treatment as it relates to the goals and/or objectives;

Member (and family, when applicable) response to the session or intervention; Any new need(s), goals and/or objectives identified during the session or service.

In addition to the items listed above : (B) a list/log/sign in sheet of participants for each Group rehabilitative or psychotherapy session and facilitating BHRS, LBHP, or CADC must be maintained; and (6) Concurrent documentation between the clinician and member can be billed as part of the treatment session time, but must be documented clearly in the progress notes and signed by the member (or note if the member is unable/refuses to sign).

Do’s & DON’Ts

Do what is clinically right for the client.

Don’t do the daily maximum allowed hours just because the policy says you can.

Don’t do the daily maximum in order to make more money.

Don’t work without the supervision/consultation of the LBHP or Clinical Director on cases.

Required Elements (PNs)- cont’d.

Progress notes for intensive outpatient mental health, substance abuse or integrated programs may be in the form of daily summary or weekly summary notes and must include the following:

Curriculum sessions attended each day and/or dates attending during the week;

Start and stop times for each day attended and the physical location in which the service was rendered;

Specific goal(s) and objectives addressed during the week;

Type of Skills Training provided each day and/or during the week including the specific curriculum used;

Member satisfaction with staff intervention(s);

Progress, or barrier to, made towards goals, objectives;

New goal(s) or objective(s) identified;

Signature of the BHRS; and Credentials of the BHRS.

Required Elements (PNs)- cont’d.

Do’s & DON’Ts – cont’d.

Do take a child to an activity, and bill only the face to face time that you spend teaching a skill or observing the client practicing that skill.

Don’t take a child to an activity and bill for the whole time.

Don’t take a group of children to an activity, go off with one child to do Individual Rehab and leave the rest unattended.

Don’t take any child that is not an enrolled client on a rehab outing.

Don’t treat a child under age 6.

Do’s & DON’Ts- cont’d.

Do sit in a child’s class to observe, then do some instruction with the child when allowable, focused on what will help them to maintain better in school and with their peers. (The observation time is not billable)

Don’t go sit in a child’s class and bill the whole time.

Most school systems do not allow for PSR to be billed during school hours.

BHRS Resources

State & Federal Authorities - www.okhca.org

Policies, Payment Rates, and Medicaid Fraud Reporting

Websites

Center for Psychosocial Rehab - www.cpr.org

Liability Insurance - www.hpso.com, www.cphins.com, etc.

THE END