Professional Development & Training Series: Behavioral Health Quality … · 2017. 6. 19. · Quality Management System-Coordinated Services * Documentation Standards-Coordinated

Subtitle

Title

1

Professional Development & Training Series:

Behavioral Health Quality Assurance (BHQA) Staff

Workshop #4: Short-Doyle Medi-Cal Rehabilitation Option &

Targeted Case Management Manual (1993):

June 2017

San Francisco Department of Public Health

Behavioral Health Services

Quality Management

Clinical Documentation Improvement Program (CDIP)

Staff contact: Joseph A Turner, PhD ([email protected])

Handouts

Build a binder for workshop materials:

Powerpoint: steal these slides for your training!

CDIP SDMC Rehab/TCM Manual Excerpts: a must-

have reference for a true QA professional

Bonus Info: Kaiser Family Foundation Report

(Rehab Option) + DHCS Information Notices Tool

Staff Contact: Joseph A Turner, PhD ([email protected]) 6/8/2017 2

Recap on the Series

Problem: People Do Not Understand…

Quality assurance…

Managed care…

BHQA staff deserve education, training & support:

Workshop 1: don’t have to memorize CCR Title 9, but…

Workshop 2: don’t have to our Medicaid State Plan, but …

Workshop 3: don’t have to memorize MHP Boilerplate, but…

Workshop 4: you don’t have to memorize the Short-Doyle

Medi-Cal Rehab Option/TCM Manual, but…

Staff Contact: Joseph A Turner, PhD ([email protected]) 6/8/2017 3

Jargon Check: Quality Assurance

4

…retrospective

comparison against

a standard

…real-time

investigation of

processes

…organized

system to monitor

& improve quality

6/8/2017Staff Contact: Joseph A Turner, PhD ([email protected])

5

Recap on the Series

6/8/2017

Federal

State

County

Provider

Workshop #1 Workshop #2 Workshop #3 Workshop #4 Workshop #5

State Plan

CCR Title 9Boilerplate

Contract

1994

SDMC

Manual

Medi-Cal

Certification

Staff Contact: Joseph A Turner, PhD ([email protected])

6

Recap: Workshop #1

“CCR Title 9”

(a regulation)

Blueprint (build a County Mental Health Plan)

Rules(operate a County Mental Health Plan)

You build a publicly funded managed care

Medicaid program by following blueprints & rules!

Recap: Workshop #1

7

The 27 Regulatory “Titles” of the California Code of Regulations (CCR)

Title 1: General Provisions Title 15: Crime Prevention & Corrections

Title 2: Administration Title 16: Professional & Vocational Regulations

Title 3: Food & Agriculture Title 17: Public Health

Title 4: Business Regulations Title 18: Public Revenues

Title 5: Education Title 19: Public Safety

Title 7: Harbors & Navigation Title 20: Public Utilities & Energy

Title 8: Industrial Relations Title 21: Public Works

Title 9: Rehabilitative & Developmental Services Title 22: Social Security

Title 10: Investment Title 23: Waters

Title 11: Law Title 24: Building Standards Code

Title 12: Military & Veterans Affairs Title 25: Housing & Community Development

Title 13: Motor Vehicles Title 26: Toxics

Title 14: Natural Resources Title 27: Environmental Protection

Regulations =

BLUEPRINTS &

RULES


8

Switching Gears…

If CCR Title 9 functions as

“blueprints and rules” for SMHS…

…what were the blueprints and rules for CCR Title 9?

…what preceded CCR Title 9?


Tracking Down Jargon

How to understand “service necessity”

How to understand “case management brokerage”

Connecting with History and Context

How to understand County “Carve Out”

What did Medi-Cal look like before?

Staff Contact: Joseph A Turner, PhD ([email protected]) 9

Backstory on the SDMC-

Rehab Option/TCM Manual

Manuals & Page-by-Page Updates

Guidance published in “manuals” that get updated over

time—only specific pages get updated




SDMC Rehab Option TCM Manual

CDIP tried to obtain all the pages (original and

updated)…

Partially successful

CDIP marked up the document to show:

original language that was updated,

updates from July 1995 and

updates from October 1995Staff Contact: Joseph A Turner, PhD ([email protected]) 11



Frankensteinian monster?




Don’t let perfection be the enemy of good!




Cover sheet

explains how

CDIP created

our local copy of

the manual


Structure of the

SDMC-Rehab Option/TCM ManualSECTION TITLE (Compact)

1

Introduction

Acknowledgements

Philosophy

2

Service Definitions *

Planned Services*

Unplanned Services*

Targeted Case Management*

Comparison of Service Functions*

Lockouts, Overrides, Computer Edits, and Other Limitations

Staffing Qualifications for Service Delivery and Documentation

3 Medical and Service Necessity *

4

Coordinated Services Summary*

Personnel Description-Coordinated Services*

Quality Management System-Coordinated Services *

Documentation Standards-Coordinated Services*

5Short-Doyle/Medi-Cal Traditional Quality Assurance and Utilization Review

Requirements for Rehabilitation and Case Management/Brokerage*6 Inpatient Hospital UR Requirements7 Provider Certification Standards*8 Definitions*9 Index

* selected

pages are

included in

workshop

handout

get the full

copy @CDIP

website

Expansion of Billable Services

Moving from Clinic Option to Rehab Option

Expansion of “Case Management/Brokerage”

Quality Assurance & Utilization Review

Models

“Traditional” vs. “Coordinated Services”


SDMC-Rehab Option/TCM

Manual: Key Concepts

The “necessity”

Medical vs. service necessity

The domains of impairment

Derived from the Community Functioning Evaluation

(CfE)


SDMC-Rehab Option/TCM

Manual: Key Concepts


Expanding Services-

M-Caid Rehab vs. Clinic Option*

Service Clinic Option Rehab Option

Inpatient Psych Hospital yes yes

Psych Health Facility no yes

Adult Residential no yes

Adult Crisis Residential no yes

Day Treatment no yes

Mental Health Services ish yes

Crisis Stabilization no yes

Case Management only client client or sig other

*see page 2-43 of Manual to see table

Rehab vs. Clinic Option Flexibility

More types of services (beyond inpatient and limited

outpatient)

More types of service providers (beyond

MD/PhD/LCSW)

More locations for services (beyond the clinic walls)


Expanding Services-

M-Caid Rehab vs. Clinic Option

Formal “Case Management”

Elements of Targeted Case Management:

Assessing, planning, brokering, monitoring

Rehabilitation Option services include

services that are “case management-like”

Managing/monitoring Medicaid planned services (e.g., Plan

Development; Assessment of case management needs)


Expanding Services-

Rehab + TCM

Limits of Rehab Option Services

“…activities geared toward gaining access to and

monitoring non-Medicaid services are not reimbursable

under the rehabilitation option”

“California has chosen to include linkage to both Medicaid

and non-Medicaid services under a Case

Management/Brokerage service function…billed as

Targeted Case Management…rather than Rehabilitation

Option.


Expanding Services-

Rehab + TCM

Targeted Case Management/Brokerage

Linkage and Consultation: identification and pursuit of

resources including:

Interagency and intra-agency consultation, communication,

coordination and referral

Monitoring service delivery system to ensure client’s access to

service/delivery system

Monitoring client’s progress

Plan Development


Expanding Services-

Rehab + TCM


Placement Services: supportive assistance to the client in the assessment and determination of need and securing adequate and appropriate living arrangements including:

Locating/securing appropriate living environment

Locating/securing funding

Preplacement visits

Negotiation of housing placement contracts

Placement and placement follow-up

Accessing services necessary to secure placement


Expanding Services-

Rehab + TCM



Expanding Services-

Rehab + TCM

Activity How to Bill

(Re)Evaluation Mental Health Services (Rehab)

Plan Development Mental Health Services (Rehab)

Linkage and Consultation Case Management/Brokerage

Placement Services Case Management/Brokerage

Assistance with Daily Living Mental Health Services (Rehab)

Emergency Intervention Crisis Intervention

*see manual page 2-42

Coordinated Services Approach to QA/UR


Quality Assurance & Utilization

Review Models

Neighborhood-

Based County

Clinics Intake

Coordination

Plan

Service

Plan

• Clients access services through clinics based in

neighborhoods

• Coordinator conducts intake over 60 days

• Coordination Plan identifies their life desires and how mental

health services can help

• Coordinator puts every service/service provider on plan

Coordinated Services Approach to QA/UR



Review Models

Neighborhood-

Based County

Clinics Intake

Coordination

Plan

Service

Plan

• Utilization Review:

• At intake/annually, is there medical necessity?

• At intake/annually, authorize services

• Utilization Control:

• Coordinator must give prior approval for all services (except

TCM)

Traditional QA Approach to QA/UR

Missing pages from manual make it hard to see

(Section 5)

Closer to what we experience today?



Review Models



Review Models


The Necessity

Medical Necessity Service Necessity

• Definition: individual’s level of

functioning, due to a mental

illness, disrupts or interferes

with community living to the

extent that without service, the

Individual would be unable to

maintain residence, engage in

productive activities and daily

responsibilities, maintain a

social support system, and keep

healthy

• 2 Criteria to Meet: diagnostic

and impairment criteria

• Definition: to be eligible for

reimbursement of Case

Management/Brokerage, the

Individual must meet A&B of the

necessity criteria.

• Note: all individuals with medical

necessity also have service

necessity


The Necessity

Medical Necessity Service Necessity

• seems to be about mental

health services, crisis

intervention, etc.

• clearly about TCM

Medical Necessity

Impairment Criteria

6/19/2017 30

Impairment in Community Functioning

Criteria (one of the following)

a. Community Functioning: (next page)

b. Psychiatric Symptoms: the person exhibits repeated presence

of psychotic symptoms OR suicidal ideation or acts OR violent

ideation or acts to persons or property.

c. Psychiatric History: the person has a psychiatric history of

recurring substantial functional impairment or symptoms. The

person's history demonstrates that without mental health service,

there is a high risk of recurrence to a level of functional

impairment/symptoms listed above.

OR

OR

Medical Necessity

Impairment Criteria

6/19/2017 31

Community Functioning: reflects the degree in which a mental health illness disrupts or

interferes with community living to the extent that without treatment and/or services, the person

would be unable to function:

(a) Living arrangements: the person lives in the community in a setting of his/her choice; for

children, they live in the home and comply with community rules

(b) Daily Activities: the person is involved in a productive daily activities (may include

involvement in household chores, scheduled programs, education and training, and employment;

for children, they are involved in age appropriate daily activities (may include involvement in

household chores, scheduled programs, education and training, and employment)

(c) Social Relationships: the person demonstrates the ability to establish and maintain

relationships and social support systems; for children, they demonstrate the ability to establish and

maintain relationships and social support systems; for children, they demonstrate the ability to

establish and maintain age appropriate social and family relationships

(d) Health: individual demonstrates the ability to maintain physical and mental hygiene and

manage own medications; for children, they experience maximum physical and mental well being,

with symptoms minimized and good access to health care services.

32

Parting Thoughts…

The SDMC Rehab Option & TCM

Manual is your friend!


SFDPH-BHS-CDIP Website:

Not a “buffet” (i.e., take what you want)

Is “pre fixe” (i.e., the chef gives you)

https://www.sfdph.org/dph/comupg/oservices/mentalHlth/CBHS/CBHSQualityMgmt.asp


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Professional Development & Training Series: Behavioral Health Quality … · 2017. 6. 19. · Quality Management System-Coordinated Services * Documentation Standards-Coordinated